A female client was horseback riding when her horse slipped and fell on her leg, crushing but not breaking it, and resulting in a large amount of edema over the crushed area. Which pathophysiological mechanism is responsible for the edema?

1. Inspect head for trauma. Head injuries can be life-threatening, so the nurse must first assess for signs of skull fractures, concussions, or intracranial bleeding that could explain the headache.
2. Perform a neurological exam. If head trauma is suspected, a neurological exam is essential to assess for altered mental status, coordination deficits, or signs of increased intracranial pressure.
3. Evaluate range of motion of all joints. After ruling out life-threatening conditions, the nurse should assess for musculoskeletal injuries, fractures, or soft tissue damage from physical abuse.
4. Provide a safety plan to prevent further violence. Once the client is medically stable, the nurse should provide resources, assess risk for further harm, and develop a safety plan to prevent future abuse.

A. Apply a zinc-based cream with brief changes. Zinc-based creams create a protective barrier against moisture and irritation from incontinence. This helps prevent skin breakdown by reducing the effects of prolonged exposure to urine and stool.
B. Apply powder to the perineum. Powder can cause clumping when mixed with moisture, increasing friction and leading to skin irritation. It is not the preferred method for preventing skin breakdown in incontinent patients.
C. Provide a donut-shaped pillow to sit on. Donut-shaped pillows create pressure points around the edges, which can worsen pressure injuries rather than prevent them. A pressure-relieving cushion is a better alternative.
D. Use an antimicrobial soap to clean skin. Harsh soaps can strip the skin of its natural protective oils, leading to dryness and irritation. A mild, pH-balanced cleanser is recommended for skin care.
E. Place a foam pad on the bed. Foam pads help redistribute pressure and reduce friction, lowering the risk of pressure injuries for patients who have limited mobility and spend extended time in bed.
F. Ensure the client slides up in bed on their own. Allowing the client to slide in bed increases friction and shearing forces, leading to skin breakdown. Assisted repositioning is necessary to prevent injury.
G. Two-person assist to move up in bed using a slide sheet. Using a slide sheet with assistance minimizes friction and shear, which are significant contributors to pressure ulcers. This method helps protect fragile skin.
H. Elevate the head of the bed above 30 degrees. Elevating the bed above 30 degrees increases pressure on the sacrum and coccyx, heightening the risk of skin breakdown. A lower elevation is preferred unless contraindicated.
I. Request a physical therapy consult. A physical therapy consult can help improve mobility, strength, and positioning techniques, reducing prolonged pressure on vulnerable areas and promoting skin integrity.