Difficulty: Medium
Average Score: 87%
Simulated
The nurse is developing a plan of care for a client who suffered a pelvic fracture following a motor vehicle crash (MVC). Which interventions should be included in the nursing care plan to prevent skin breakdown? Select all that apply.
Correct answer
A,C,D,E
Rationale
The client in this question is at high risk for pressure injury. Interventions for prevention of pressure injuries include minimizing the force and friction applied to the skin; performing a systematic skin inspection at least once a day, giving particular attention to the bony prominences; cleansing the skin at the time of soiling and at routine intervals; avoiding the use of hot water; and using a mild cleansing agent that minimizes irritation and dryness of the skin. Pillows should be used to keep the knees and other bony prominences from direct contact with one another, because skin contact can promote breakdown. Massaging over bony prominences (especially vigorous) can be harmful to at-risk skin surfaces.