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QOD 58: Intervention for Pressure Ulcer (Integumentary/Basic Care and Comfort)


A nurse is working with a client who has been confined to his bed for the past week because of illness. While turning this patient, the nurse notes a stage II pressure ulcer on his sacrum. Which action is most appropriate in responding to this finding? Select all that apply.


D. Support the patients nutrition and mobility

E. Relieve pressure using pillows or foam cushions


Pressure ulcers are unfortunate consequences of immobility; if the nurse finds a pressure ulcer on a patient, she must respond quickly to avoid further complications. The nurse should apply a dressing and medication as ordered, as well as quickly relieve pressure from the site using foam cushions or pillows. The nurse must avoid donut-shaped ring devices for support as these place too much pressure in certain areas. The nurse also should not massage the site, as this can cause tissue damage.

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