A sedated patient is at risk for the development of pressure ulcers. Which of the following nursing interventions is appropriate for the prevention of pressure ulcers?

Daily washing with mild cleanser and lotion
Supplemental nutrition
Turn the patient every 2 hours

Explanation

• Prevention of pressure ulcers is a major role of the nurse.  Adequate nutrition and hydration are essential for the prevention and treatment of pressure ulcers. Nutritional supplementation may be needed if the patient is not eating or has a low serum albumin level.

• Sedated or bed-bound patients should be assisted with self-care or given bed baths daily. Avoid hot water and use a pH balanced skin cleanser. Maintain skin hydration by applying lubricating moisturizers and creams with minimal alcohol content. Use protective barriers (e.g., skin protectant cream, transparent films, hydrocolloids) to reduce friction injuries.

• Other interventions include repositioning at least every 2 hours (or sooner, if at high risk), use of devices to relieve pressure on the heels and bony prominences of the feet, and turning the patient 30º to either side to avoid pressure on the trochanter.

• Shearing forces should be reduced by keeping the head of the bed at the lowest level consistent with medical condition (30º or lower is recommended) and by using transfer or lifting devices to avoid dragging patients on the bedsheets.

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