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Difficulty: MediumBasic Care and Comfort

A nurse is developing a plan of care for an older adult client who is largely immobile and has a newly identified Stage 3 sacral pressure injury. Which of the following basic care and comfort interventions should the nurse include? Select all that apply.

  1. Reposition the client at least every 2 hours using a 30-degree lateral tilt position.Answer
  2. B
    Maintain the head of the bed continuously elevated at an 80-degree angle to support respiratory function.
  3. Utilize a friction-reducing device, such as a lift sheet, when repositioning the client in bed.Answer
  4. D
    Delegate the daily assessment of the sacral wound margins and exudate to the unlicensed assistive personnel (UAP).
  5. E
    Explain to the family that significant skin breakdown on the sacrum is a normal, expected physiological consequence of advanced age.
  6. Provide nutritional supplements that are high in protein and vitamin C between scheduled meals.Answer

Answer

The correct interventions are repositioning the client using a 30-degree lateral tilt, utilizing a friction-reducing device during movement, and providing high-protein, vitamin C-rich nutritional supplements.
Interventions that safely reduce pressure (30-degree lateral tilt), prevent friction (lift sheets), and provide building blocks for tissue repair (protein and vitamin C) are essential, evidence-based components of basic care and comfort for a client with a pressure injury.

Step-by-Step Solution

1
Identify the primary clinical goals for a client with a Stage 3 sacral pressure injury.
Goals include offloading pressure, preventing further tissue damage from shearing or friction, and promoting systemic wound healing.
Establishing goals ensures that selected basic care and comfort interventions directly address the underlying pathophysiology of the injury.
2
Evaluate the positioning and mobility interventions for safety and efficacy.
A 30-degree lateral tilt and the use of lift sheets are safe, effective methods to reduce pressure and shear. A high Fowler's position increases sacral shear and is contraindicated.
Improper positioning is a primary driver of pressure injury progression.
3
Assess the nutritional and delegation interventions against nursing standards of practice.
Protein and vitamin C are essential for healing and should be provided. Delegating wound assessment to a UAP is unsafe and outside their scope of practice.
The registered nurse must retain responsibility for clinical assessments, while ensuring the client receives the metabolic support necessary for tissue repair.

Key Concept

Basic care measures for severe pressure injuries focus on offloading pressure (30-degree tilt), minimizing shear/friction (lift sheets), and optimizing nutritional status (protein/vitamin C), while retaining clinical assessments within the RN scope of practice.
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Basic Care and Comfort

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