Which of the following intervention can best prevent the bed sore?

HPSSSB Staff Nurse - 2016

Fundamental of Nursing

Medium

Appeared in: HPSSSB Staff Nurse - 2016

Explanation

The primary cause of bed sores (pressure ulcers) is sustained, unrelieved pressure on the skin, especially over bony prominences.
Changing the patient's position every 2 hours is the most effective intervention because it directly relieves this pressure, allowing blood to flow back to the tissues (reperfusion) and preventing ischemic injury.
This simple, consistent action is the cornerstone of all pressure ulcer prevention protocols, as unrelieved pressure can cause tissue damage in as little as two hours.
International guidelines emphasize that repositioning is a fundamental standard of care for at-risk individuals.

Option A: While keeping the skin clean and dry is crucial for maintaining skin integrity and preventing moisture-related damage, it does not address the primary cause of bed sores, which is pressure.
Option B: Massaging reddened areas is contraindicated. The redness indicates underlying tissue inflammation and compromised blood flow. Massage can cause further damage to fragile capillaries and worsen the injury.
Option D: Specialty mattresses (water, air, gel) are pressure-redistributing surfaces. They are important adjuncts that reduce the intensity of pressure, but they do not completely eliminate it. They cannot replace the need for regular repositioning.

Clinical Relevance

Nursing practice connection: Knowing Priority nursing intervention for pressure ulcer (bedsore) prevention helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Failure to implement and document a consistent turning schedule is a major patient safety issue and a common reason for litigation in healthcare.
Nurses use risk assessment tools like the Braden Scale to identify patients at risk for pressure ulcers. A lower score indicates higher risk, necessitating more aggressive preventive measures like a specialty mattress and a strict turning schedule.
What if? The patient refuses to be turned due to pain. The nurse's first action would be to assess the cause of the pain, administer prescribed analgesics 30-60 minutes before the scheduled turn, and then use pillows and wedges to make small, frequent shifts in position (micro-shifts) to offload pressure.

How to Approach the Question

First, identify the core question: It asks for the 'best' intervention to 'prevent' bed sores.
Analyze the underlying cause of bed sores: sustained pressure that cuts off blood supply to the skin.
Evaluate each option based on how directly it addresses this primary cause.
Option A (hygiene) is supportive but doesn't relieve pressure.
Option B (massage) is harmful and outdated.
Option D (mattress) helps reduce pressure but doesn't eliminate it.

Concept Tested & Keywords

Concept Tested: Priority nursing intervention for pressure ulcer (bedsore) prevention.
Stem keywords: intervention, prevent, bed sore
Lead-in keywords: best

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