The nurse provides an in-service for hospital staff on how to prevent pressure injuries in clients with limited mobility. Which instructions are appropriate for the nurse to include? Select all that apply.

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11ecbb05_cb10_cff5_b433_a98d0cea446a_MD0009_00 Pressure injuries develop from external pressure compressing capillaries and underlying soft tissue, or from friction and shearing forces. The nurse should assess every client's risk for pressure injuries (using the Braden scale) upon admission and at least once daily during hospitalization. To prevent pressure injuries: Use emollients and barrier creams to hydrate, protect, and strengthen the skin (Option A).Use foam padding on chairs, commode seats, and other surfaces to help reduce pressure on bony prominences (Option D).Provide prompt incontinence care and use additional barrier cream to keep skin clean and dry; this will further help reduce irritation and associated breakdown of the skin (Option B).Reposition clients with a turn sheet every 2 hours using devices (eg, pillows, foam wedges) to maintain position; avoid pulling/dragging the client up in bed, as shearing can occur. Use emollients and barrier creams to hydrate, protect, and strengthen the skin (Option A). Use foam padding on chairs, commode seats, and other surfaces to help reduce pressure on bony prominences (Option D). Provide prompt incontinence care and use additional barrier cream to keep skin clean and dry; this will further help reduce irritation and associated breakdown of the skin (Option B). Reposition clients with a turn sheet every 2 hours using devices (eg, pillows, foam wedges) to maintain position; avoid pulling/dragging the client up in bed, as shearing can occur. (Option C) Massage is not an acceptable intervention for pressure injury prevention as it can lead to deep tissue damage. It is contraindicated in the presence of inflammation, damaged blood vessels, or fragile skin. (Option E) Clients must be repositioned and turned every 2 hours. Turning clients every 6 hours is too infrequent and will not confer the same protection against pressure and associated tissue ischemia. Educational objective: Skin assessment, proper skin care, repositioning every 2 hours, adequate nutrition, and proper support surfaces are effective in helping prevent pressure injuries. Massage over the bony prominences is not recommended for pressure injury prevention.

The Nurse Provides an In-Service for Hospital Staff on How