Question

When caring for the client who is at risk for developing pressure ulcers, the nurse should avoid which one of the following? A. Cleansing the skin with a pH-balanced soap B. Lubricating the skin with a moisturizing cream C. Massaging reddened areas of the skin D. Using absorbent garments for incontinence

Short answer

A) Cleansing the skin with a pH-balanced soap B) Lubricating the skin with a moisturizing cream C) Massaging reddened areas of the skin D) Using absorbent garments for incontinence Answer: C) Massaging reddened areas of the skin

Step-by-step solution

Recognize the best practices for preventing pressure ulcers

In order to prevent pressure ulcers, it is important to maintain proper skin hygiene, moisturize the skin, avoid friction and shear, and manage incontinence properly. Let's analyze each option provided in the question to see which one is not recommended for a client at risk for pressure ulcers.

Analyze option A

Option A suggests cleansing the skin with a pH-balanced soap. This is a good practice, as maintaining skin hygiene is crucial to prevent pressure ulcers. Therefore, option A is not the correct answer.

Analyze option B

Option B suggests lubricating the skin with a moisturizing cream. This practice is also recommended, as it helps to maintain skin barrier function and prevent skin breakdown. Therefore, option B is not the correct answer.

Analyze option C

Option C suggests massaging reddened areas of the skin. This practice is not recommended, as it can lead to further damage to the skin and underlying tissues in a client at risk for pressure ulcers. Therefore, option C is the correct answer.

Analyze option D

Option D suggests using absorbent garments for incontinence. Managing incontinence is important in preventing pressure ulcers, as excessive moisture can lead to skin breakdown. Therefore, option D is not the correct answer.

Conclusion

After analyzing all the options, we can conclude that the nurse should avoid option C, massaging reddened areas of the skin, when caring for a client who is at risk for developing pressure ulcers.

Key concepts

Skin Hygiene

Maintaining proper skin hygiene is essential in preventing pressure ulcers. It involves keeping the skin clean to prevent infection and irritation. Cleansing the skin with a pH-balanced soap is particularly beneficial because it helps to maintain the natural balance of the skin's protective barrier.
Overly harsh soaps can strip the skin of essential oils that are necessary for maintaining this barrier.

• Gentle cleaning removes bacteria and debris that could irritate the skin.
• Regular washing helps prevent the buildup of sweat and oils, reducing the risk of skin breakdown.
• A pH-balanced approach ensures that the skin's natural flora remains intact, promoting health and resilience.

In essence, consistent and gentle cleansing helps to maintain the skin's integrity, making it less susceptible to damage and ulcer development.

Moisturizing Skin

Moisturizing is an essential step in caring for skin at risk of pressure ulcers. Using a moisturizing cream or lotion helps to keep the skin soft and pliable.
This reduces the likelihood of cracking or breaking, which can lead to ulcers.
Moisturizers work by adding moisture to the skin and sealing it to prevent loss.

• Improves skin elasticity, allowing it to stretch without tearing.
• Helps in maintaining the moisture barrier, fortifying the skin against external pressures.
• Reduces itchiness and discomfort, which can prevent excessive scratching.

Incorporating a good moisturizer into daily skin care can make a significant difference in pressure ulcer prevention by enhancing overall skin health.

Incontinence Management

Managing incontinence is critical in preventing pressure ulcers due to the associated risks of excessive moisture and friction. Incontinence can expose the skin to urine or feces, which can be very irritating and damaging. Absorbent garments, when used appropriately, help protect the skin by wicking away moisture.

• Regular checks and changing of absorbent pads can prevent prolonged wetness.
• Promptly addressing accidents reduces the risk of irritation and skin breakdown.
• Using barrier creams alongside absorbent garments adds additional protection.

Effective incontinence management procedures can significantly reduce the chances of developing pressure ulcers by keeping the skin clean and dry.

Nursing Best Practices

Nursing best practices in avoiding pressure ulcers revolve around proactive care measures. Nurses are trained to recognize risks and take preventative actions. Regular re-positioning of patients helps to relieve pressure on vulnerable skin areas.
Moreover, educating patients and families about the importance of skin care can make a big difference.

• Regular skin assessments to identify early signs of pressure ulcers.
• Appropriate use of support surfaces like mattresses or cushions to redistribute pressure.
• Collaborative care approaches ensure all aspects of pressure ulcer risk are addressed effectively.

Following these best practices can significantly lower the risk of ulcers and enhance patient outcomes by integrating comprehensive care approaches.