A nurse plans care for a client who is immobile.
Which interventions would the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.)

Choice A rationale

Placing a small pillow between bony surfaces effectively redistributes pressure, preventing the sustained compression that leads to tissue ischemia. This action minimizes direct bone-on-bone contact and provides cushioning, which enhances blood flow to the skin and subcutaneous tissues. The goal is to avoid prolonged pressure on any single area, thereby mitigating the risk of capillary occlusion and subsequent pressure sore formation.

Choice B rationale

Elevating the head of the bed to 45 degrees increases the risk of shearing forces. Shearing occurs when the skin remains stationary while the underlying tissue shifts and moves, stretching and tearing small blood vessels. This disrupts circulation, making the tissue more susceptible to ischemia and breakdown. A lower angle, typically 30 degrees or less, is recommended to minimize this damaging effect and reduce the risk of pressure sore development.

Choice C rationale

Limiting fluids and proteins in the diet is counterproductive. Adequate hydration is essential for maintaining skin turgor and tissue perfusion. Protein is a critical component for tissue repair and cell regeneration. A deficiency in these nutrients impairs the body’s ability to heal existing wounds and makes the skin more fragile and susceptible to injury, significantly increasing the risk of pressure sore formation.

Choice D rationale

Using a lift sheet is a fundamental intervention for safe repositioning. It prevents the friction and shear that occur when a client is dragged across a surface. Friction is the mechanical force of two surfaces rubbing against each other, which can strip away the outer layers of the epidermis. A lift sheet protects the skin by ensuring smooth, controlled movements, thus preserving skin integrity and reducing the risk of pressure sores.

Choice E rationale

Repositioning a client in a chair every 2 hours is insufficient. The pressure exerted on the buttocks and sacrum when seated is typically greater than when lying in bed. Therefore, clients in a chair should be repositioned or encouraged to shift their weight more frequently, usually every hour, to relieve pressure points. This more frequent movement prevents sustained compression and promotes adequate blood flow to the at-risk areas.

Choice F rationale

Keeping the client's heels off the bed surfaces is crucial because heels are highly susceptible to pressure sore formation. They are bony prominences with limited subcutaneous fat, making them particularly vulnerable to sustained pressure. Placing a pillow under the calves to float the heels completely off the bed effectively eliminates this pressure, ensuring continuous blood flow to the heel tissue and preventing ischemic damage.

Choice G rationale

Using a rubber ring to decrease sacral pressure is a harmful practice. A rubber ring, or donut cushion, actually increases pressure on the surrounding tissues, leading to a "donut-shaped" area of ischemia. The hole in the middle of the ring focuses pressure around the edges, disrupting blood flow and increasing the risk of tissue breakdown. Specialized cushions that distribute pressure evenly are the recommended alternative.