The nurse plans care to protect the skin covering an older adult's greater trochanter.Which of the following interventions is the nurse's priority when the older adult is positioned on the side?

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The most important nursing intervention when an older adult is positioned on the side is to relieve pressure on the head of the femur and the greater trochanter; the greater trochanter is the most prominent bony projection on the side of a body.By turning the older adult at intervals,the nurse helps maintain tissue perfusion,thus providing oxygenation to tissues and allowing the removal of waste from vulnerable skin.The nurse places a pillow between the knees to help maintain physiological body alignment and to prevent strain on the hips and spine; if positioned properly,the pillow can help maintain tissue integrity of the medial malleolus and ankle by elevating them off the mattress.However,because the nurse's priority is to maintain tissue oxygenation,preventing muscle and joint strain is not as important.The nurse keeps the skin clean and dry to help maintain skin integrity,but this intervention is not as important as maintaining tissue oxygenation.The nurse uses the Sims' position to supplement turning; when in the Sims' position,the patient is on the side but rotated slightly forward,allowing the chest and abdomen to fall forward to relieve some of the pressure on the patient's side.

The Nurse Plans Care to Protect the Skin Covering an Older