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Difficulty: HardBasic Care and Comfort

A nurse is planning skin integrity and comfort measures for an intubated client with severe acute respiratory distress syndrome (ARDS) who is undergoing therapeutic prone positioning. Which action is the most appropriate to include in the plan of care to protect the client's skin and promote safety?

  1. Apply prophylactic foam or hydrocolloid dressings to the client's forehead, cheeks, and chin prior to placing the client in the prone position.Answer
  2. B
    Maintain the client's head turned to one side continuously during the entire prone session to ensure the endotracheal tube remains securely aligned.
  3. C
    Elevate the head of the bed to a 45-degree angle while the client is prone to decrease the risk of ventilator-associated pneumonia and reduce facial edema.
  4. D
    Delegate the task of repositioning the client's head every two hours to the unlicensed assistive personnel (UAP) to maintain consistent pressure relief.

Answer

The most appropriate action is to apply prophylactic foam or hydrocolloid dressings to the face (forehead, cheeks, chin) prior to initiating the prone position to prevent pressure injuries.
Applying prophylactic barrier dressings to the face is a critical, evidence-based basic care intervention. It minimizes friction, manages microclimate, and redistributes the intense pressure placed on the facial bones, significantly reducing the risk of deep tissue injury during the 12 to 16 hours the client remains prone.

Step-by-Step Solution

1
Identify the primary basic care risks associated with prone positioning in intubated clients.
The client is at extreme risk for pressure injuries on the dependent surfaces, particularly the face, anterior shoulders, chest, and knees.
Therapeutic proning lasts for extended periods (typically 12-16 hours), placing intense, unyielding pressure on bony prominences that are not accustomed to weight-bearing.
2
Evaluate the proposed skin and safety interventions against evidence-based care guidelines.
Prophylactic dressings are recommended; continuous static head positioning causes necrosis; 45-degree elevation is anatomically impossible in prone; and airway manipulation cannot be delegated.
Ensures the selected nursing action effectively balances comfort and skin integrity with critical care airway security.

Key Concept

Pressure injury prevention and safe positioning protocols for clients in therapeutic prone positions.
Estimated Time:2m 0s
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Topics

Basic Care and Comfort

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