An immobile, elderly male client has a blood pressure of 138/60. What is an appropriate nursing action to prevent skin breakdown?

An immobile, elderly male client has a blood pressure of 138/60. What is an appropriate nursing action to prevent skin breakdown?

• A. Turn the client q2h
• B. Administer a diuretic as ordered
• C. Provide frequent ROM exercises
• D. Encourage caffeine intake to increase alertness

Answer: (A)

Relieving constant pressure on the skin is essential to prevent skin breakdown in an immobile, elderly client. When someone cannot move, pressure from body weight over bony areas (like the sacrum, heels, and hips) reduces blood flow to the skin and underlying tissue, leading to tissue damage and ulcers. Turning the patient every two hours changes the contact points, redistributes weight, and improves local circulation, which together help keep the skin healthy. Giving a diuretic won’t prevent skin breakdown; it affects fluid balance and can even worsen skin condition if it leads to dehydration or electrolyte shifts. Providing ROM exercises helps maintain joint mobility and may aid circulation, but it doesn’t sufficiently relieve sustained pressure when the patient is immobile. Encouraging caffeine intake has no role in preventing pressure ulcers and could introduce unnecessary risks. Focusing on regular repositioning, along with skin care and pressure-relieving surfaces, is the most effective approach to protect the skin.

Relieving constant pressure on the skin is essential to prevent skin breakdown in an immobile, elderly client. When someone cannot move, pressure from body weight over bony areas (like the sacrum, heels, and hips) reduces blood flow to the skin and underlying tissue, leading to tissue damage and ulcers. Turning the patient every two hours changes the contact points, redistributes weight, and improves local circulation, which together help keep the skin healthy.

Giving a diuretic won’t prevent skin breakdown; it affects fluid balance and can even worsen skin condition if it leads to dehydration or electrolyte shifts. Providing ROM exercises helps maintain joint mobility and may aid circulation, but it doesn’t sufficiently relieve sustained pressure when the patient is immobile. Encouraging caffeine intake has no role in preventing pressure ulcers and could introduce unnecessary risks. Focusing on regular repositioning, along with skin care and pressure-relieving surfaces, is the most effective approach to protect the skin.