The home health nurse learns that an elderly patient isn't able to get to the grocery store.She doesn't have much food in her home,and eats and drinks little.Most of her time is spent sitting in her chair watching television,often not realizing that she has bladder leakage.Which nursing actions would she implement to reduce the risk of developing a pressure ulcer? Select all that apply.

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Immobility is a major cause of skin breakdown,especially when skin integrity is already compromised with poor nutritional status and poor hydration.Therefore,it is very important for the patient to get up out of the chair and move around periodically.The moisture from wet clothing is a source of skin breakdown.The nurse would not only need to help the woman put on dry undergarments but also implement a plan for incontinence care including using protective pads and absorption garments.Clean skin is important for optimizing skin integrity.However,soap can be drying to the skin,which could increase risk of alterations in skin integrity.Although this patient is at risk for dehydration and undernourishment,which compromises skin integrity,the nurse should educate the patient to drink noncaffeinated fluids,especially water.Caffeine can aggravate incontinence.

The Home Health Nurse Learns That an Elderly Patient Isn't