A nurse is caring for a client whose Braden Scale score is 9. What intervention demonstrates a lack of evidence-based knowledge?

Choice A rationale

The 44-year-old client with pneumonia receiving intravenous antibiotics is at some risk due to potential immobility and fever, which can lead to diaphoresis and skin maceration. However, this client is likely mobile enough to shift positions independently or with minimal assistance, reducing the risk of sustained pressure. The client's age and general health status, aside from the acute infection, suggest good tissue perfusion and skin integrity.

Choice B rationale

A 26-year-old who is bedridden with a fractured leg is at significant risk due to immobility. The inability to shift weight and relieve pressure on bony prominences can lead to ischemia and tissue damage. However, younger individuals generally have better vascular supply, skin turgor, and faster cellular regeneration compared to older adults, which provides some protective physiological advantage against pressure injury development.

Choice C rationale

This 65-year-old client is at the greatest risk due to a combination of multiple risk factors. Hemiparesis leads to immobility and the inability to reposition, causing prolonged pressure on one side of the body. Incontinence exposes the skin to moisture and chemical irritants from urine and feces, leading to maceration and a breakdown of the skin's protective barrier, making it more susceptible to injury.

Choice D rationale

A 78-year-old requiring a walker for ambulation is at a lower risk for pressure injuries compared to a bedridden individual. Although advanced age and the need for assistive devices suggest some mobility limitations, the ability to ambulate, even with assistance, indicates the capacity to shift weight and relieve pressure on a regular basis. This regular movement promotes circulation and prevents prolonged periods of immobility.

Choice A rationale

A Braden Scale score of 9 indicates a high risk for pressure injury. Requesting a referral to a registered dietitian nutritionist is an evidence-based intervention because poor nutrition, particularly protein and calorie deficiency, is a significant risk factor for skin breakdown and impaired wound healing.

Choice B rationale

Keeping the head of the bed raised no more than 45 degrees is an evidence-based practice to prevent pressure injuries. This position reduces the risk of shear and friction forces on the sacrum, which can lead to tissue damage and pressure ulcer formation.

Choice C rationale

Performing perineal cleansing every 2 hours is not an evidence-based intervention for a Braden Scale score of 9. Frequent cleansing can cause excessive moisture, which macerates the skin and increases the risk of breakdown. Cleansing should be done as needed, not on a rigid schedule.

Choice D rationale

Daily skin assessment is a fundamental and evidence-based intervention for all clients at risk for pressure injuries. A Braden score of 9 signifies a high-risk client, and a daily head-to-toe skin assessment is crucial for early detection of erythema or other signs of skin breakdown.