A bedridden patient has been lying in the same position for several hours. Which nursing intervention is most important to prevent pressure ulcers?

1. A

   Apply talcum powder

2. B

   Change position every 2 hours

3. C

   Increase room temperature

4. D

   Give high protein diet only

Appeared in: AIIMS Delhi NO- 2019

Explanation

• Pressure ulcers are caused by prolonged, unrelieved pressure on the skin, which cuts off blood flow and leads to tissue death (ischemia).
• Changing the patient's position at least every 2 hours is the most direct and effective intervention to relieve this pressure, restore circulation, and prevent skin breakdown.
• This intervention addresses the root cause of the problem, making it the highest priority.
• A 2-hour turning schedule is a fundamental and universally recognized standard of care for preventing pressure ulcers in immobile patients.

Why Other Options Were Wrong

• Option A: Talcum powder is generally avoided because it can combine with moisture to form an abrasive paste, increasing friction and skin irritation. It can also be inhaled, causing respiratory issues.
• Option C: Increasing room temperature can cause the patient to sweat, leading to excess moisture on the skin. This moisture (maceration) softens the skin, making it more vulnerable to breakdown from pressure and friction.
• Option D: While adequate nutrition, especially protein, is crucial for maintaining skin integrity and healing, it is a supportive intervention. It cannot prevent pressure ulcers if the primary cause (pressure) is not eliminated. The word 'only' makes this option too restrictive and incorrect.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Pressure Ulcer Prevention to guide bedside assessment, documentation, and the next nursing action.
• Nurses are at the forefront of pressure ulcer prevention. This involves regular risk assessment using tools like the Braden Scale, implementing a turning schedule, and educating the patient and family.
• Preventing pressure ulcers is a key indicator of nursing care quality. Their development can lead to severe pain, infection, longer hospital stays, and increased healthcare costs.
• What if? If a patient has an unstable spinal injury and cannot be turned, the most important intervention shifts to using a specialized pressure-redistributing surface, such as a low-air-loss or air-fluidized bed, to manage pressure without repositioning.

How to Approach the Question

• First, identify the question type. This is a priority question, asking for the 'most important' intervention.
• Next, identify the core clinical problem: a bedridden patient at risk for pressure ulcers.
• Recall the pathophysiology of pressure ulcers: they are primarily caused by unrelieved pressure.
• Evaluate each option to see which one most directly addresses this primary cause.
• Applying powder, adjusting temperature, and diet are all secondary or supportive measures. Some are even contraindicated.
• Changing position is the only option that directly removes the cause (pressure), making it the highest priority and the correct answer.

Concept Tested & Keywords

• Concept Tested: Pressure Ulcer Prevention
• Stem keywords: bedridden patient, same position, prevent pressure ulcers
• Lead-in keywords: most important
• Negative lead-in flag: false

Question ID

Q0fhgnY1Z_XeJkdFuwPHKI

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 pp. 109-111, 111-113