Pressure ulcers are defined as an injury to the skin and/or underlying tissue resulting from pressure or in combination with shear, usually over a bony prominence. As a nurse, what do you know you must do to prevent pressure ulcers? (Select all that apply.)

Choice A: Protect the skin from trauma. This is a correct answer. Purpura is the discoloration of the skin or mucous membranes due to hemorrhage from small blood vessels¹. It can be caused by various factors, such as blood clotting disorders, medications, infections, or weak blood vessels². Older adults are more prone to develop purpura because their skin becomes thinner and more fragile with age³. Therefore, protecting the skin from trauma, such as knocking against hard surfaces, can help prevent or reduce purpura.

Choice B: Remind the health care personnel to be gentle when handling this client’s skin. This is also a correct answer. Health care personnel should be aware of the risk of purpura in older adults and handle their skin with care. They should avoid applying excessive pressure, friction, or shear forces to the skin, as these can cause damage to the blood vessels and result in purpura. They should also use soft and smooth materials, such as cotton or silk, when dressing or cleaning the skin.

Choice C: Wear a long-sleeved shirt. This is not a correct answer. Wearing a long-sleeved shirt may provide some protection to the skin, but it is not enough to prevent purpura. Moreover, wearing tight or rough clothing can actually worsen the condition by causing irritation or injury to the skin. Therefore, this is not a good advice for the client.

Choice D: Tape a nonadherent dressing over the site of a skin tear. This is another correct answer. A skin tear is a type of wound that occurs when the skin is separated from the underlying tissue, usually due to trauma. Skin tears are common in older adults and can lead to purpura if the blood vessels are damaged. Taping a nonadherent dressing over the site of a skin tear can help protect the wound from infection, promote healing, and prevent further bleeding.

Choice A reason: Older adult’s self-report is not the most helpful tool, as it may not be reliable or consistent in older adults, especially if they have cognitive impairment, communication difficulties, or cultural barriers. Older adults may also underreport or overreport their pain due to fear, stoicism, or expectations.

Choice B reason: FPS-R (Faces Pain Scale-Revised) is not the most helpful tool, as it may not be suitable or valid for older adults, especially if they have visual impairment, facial paralysis, or dementia. FPS-R is a pictorial scale that uses six facial expressions to represent different levels of pain intensity, from 0 (no pain) to 10 (very much pain).

Choice C reason: Pain medication frequency is not the most helpful tool, as it may not reflect the actual pain level or the effectiveness of the pharmacotherapy. Pain medication frequency may vary depending on the type, dose, route, and duration of the medication, as well as the individual response and tolerance of the older adult.

Choice D reason: Older adult's pain diary is the most helpful tool, as it can provide a comprehensive and longitudinal record of the pain experience, including the location, intensity, quality, frequency, duration, triggers, relievers, and impact of the pain. A pain diary can also help track the use and response of the comfort measures, activity, and pharmacotherapy, and identify the patterns and trends of the pain.

Choice E reason: None of the above is not the correct answer, as there is one choice that is the most helpful tool for the nurse to use.