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?
- Apply prophylactic foam or hydrocolloid dressings to the client's forehead, cheeks, and chin prior to placing the client in the prone position.Cevap
- BMaintain the client's head turned to one side continuously during the entire prone session to ensure the endotracheal tube remains securely aligned.
- CElevate 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.
- DDelegate the task of repositioning the client's head every two hours to the unlicensed assistive personnel (UAP) to maintain consistent pressure relief.
Cevap
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.
Adım Adım Çözüm
Anahtar Kavram
Pressure injury prevention and safe positioning protocols for clients in therapeutic prone positions.
Tahmini Süre:2m 0s