To prevent bed sores, a nurse has to?

Appeared in: RUHS, Jaipur, PB B.Sc Nursing Entrance-2021

Explanation

The primary cause of pressure ulcers (bed sores) is sustained, unrelieved pressure on the skin, which obstructs blood flow and leads to tissue necrosis.
Changing a patient's position every two hours is the most effective intervention because it directly relieves this pressure, allowing for reperfusion of the tissues.
This simple action prevents the cascade of events leading from pressure to ischemia and eventual skin breakdown.
While other measures are supportive, repositioning is the cornerstone of pressure ulcer prevention for immobile patients.

Option A: Providing food is important for overall health and tissue resilience but does not address the primary cause of pressure ulcers, which is unrelieved pressure.
Option B: Bathing maintains skin hygiene and prevents breakdown from moisture, but it does not relieve the pressure that cuts off circulation.
Option C: Observation is a critical assessment and monitoring tool for early detection, not a preventive action. By the time a change is observed, the injury process has already begun.

Clinical Relevance

Nursing practice connection: Knowing Prevention of pressure ulcers (bed sores) in immobile patients helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Preventing pressure ulcers is a fundamental nursing responsibility and a key indicator of quality of care. They are considered a 'never event' in many healthcare systems, meaning they are largely preventable with proper care.
Nurses must meticulously document all repositioning on a turning chart or in the electronic health record to ensure consistency and accountability.
What if? If a patient has a spinal injury and cannot be turned, the primary intervention shifts from manual repositioning to using a specialized pressure-redistributing surface, such as a low-air-loss or alternating pressure mattress, to continuously relieve pressure.

How to Approach the Question

First, identify the core concept of the question: preventing bed sores (pressure ulcers).
Recall the primary cause of pressure ulcers, which is sustained, unrelieved pressure on the skin.
Evaluate each option based on how directly it addresses this primary cause.
Option A (food), B (bath), and C (observation) are all important components of care but are secondary to relieving pressure.
Option D (changing position) is the only action that directly removes the cause (pressure).
Therefore, select the option that provides the most direct and effective preventive action.

Concept Tested & Keywords

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E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 p. 109-111

E6 Nursing Fundamentals Potter Perry 12e Part 4 p. 156-158

Practise the full RUHS, Jaipur, PB B.Sc Nursing Entrance-2021

Attempt every question from this paper in a timed mock, then review the full solution for each one.