Examkin

Question

Difficulty: HardBasic Care and Comfort

A client with severe chronic obstructive pulmonary disease (COPD) and a high risk for sacral pressure injuries is confined to bed. The client reports significant shortness of breath if the head of the bed is lowered below 45 degrees. Which action by the practical nurse is the most appropriate to promote skin integrity while maintaining respiratory function?

  1. Use pillows to maintain a 30-degree laterally inclined position while keeping the head of the bed elevated.Answer
  2. B
    Lower the head of the bed to a flat position for 15 minutes every two hours to relieve sacral pressure.
  3. C
    Place a ring-shaped cushion directly under the client's sacrum while maintaining the high-Fowler's position.
  4. D
    Elevate the client's legs above the level of the heart using a wedge pillow to redistribute weight away from the pelvis.

Answer

The most appropriate action is to use pillows to maintain a 30-degree laterally inclined position while keeping the head of the bed elevated.
In clients with severe orthopnea, the head of the bed must remain elevated to facilitate diaphragmatic excursion and oxygenation. To prevent shear and pressure on the sacrum while the head is elevated, the nurse should use a 30-degree laterally inclined position. This evidence-based angle effectively offloads the sacrum and greater trochanter without compromising the client's respiratory effort.

Step-by-Step Solution

1
Analyze the competing physiological needs of the client.
The client requires an elevated head of bed (above 45 degrees) for adequate ventilation (ABCs), but this upright position increases shearing forces and pressure on the sacrum.
Airway and breathing are always the highest priority, so the head of the bed cannot be lowered.
2
Evaluate positioning alternatives that accommodate both needs.
A 30-degree lateral turn shifts body weight off the sacrum and greater trochanter without requiring the client to lie flat.
This specific angle prevents pressure on bony prominences while allowing the upper body to remain supported and elevated for lung expansion.
3
Identify and eliminate contraindicated devices or positions.
Ring cushions (which cause ischemia) and leg elevation (which increases venous return and cardiac workload) are eliminated as unsafe.
Evidence-based practice prohibits the use of doughnut cushions, and cardiopulmonary principles contraindicate excessive venous return in severe respiratory compromise.

Key Concept

Basic Care and Comfort: Positioning and Pressure Injury Prevention
Rate this question

Topics

Basic Care and Comfort

More questions from this topic