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Answer :
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Shearing forces-rationale: friction, impaired circulation, localized pressure, and shearing forces are all risk factors of pressure ulcer development; trapeze use reduces shearing forces. shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis) can occur as clients slide down in bed or are pulled up in bed. subcutaneous skin layers adhere to the sheets while deeper layers, muscle, and bone slide in the direction of movement. to reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move him up in bed, and keep the head of the bed no higher than 30 degrees.client needs category: physiological integrityclient needs subcategory: basic care and comfortcognitive level: applicationreference: taylor, c., et al. fundamentals of nursing: the art and science of nursing care, 6th ed. philadelphia: lippincott williams & wilkins, 2008, p. 1196.
Shearing forces-rationale: friction, impaired circulation, localized pressure, and shearing forces are all risk factors of pressure ulcer development; trapeze use reduces shearing forces. shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis) can occur as clients slide down in bed or are pulled up in bed. subcutaneous skin layers adhere to the sheets while deeper layers, muscle, and bone slide in the direction of movement. to reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move him up in bed, and keep the head of the bed no higher than 30 degrees.client needs category: physiological integrityclient needs subcategory: basic care and comfortcognitive level: applicationreference: taylor, c., et al. fundamentals of nursing: the art and science of nursing care, 6th ed. philadelphia: lippincott williams & wilkins, 2008, p. 1196.
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Final answer:
By having the client use the overbed trapeze to move, the nurse is reducing the risk of pressure ulcer or bedsore development. This is achieved by changing the areas of the body bearing weight and improving blood circulation in these areas. The preventative measure is commonly practiced in health facilities to prevent the development of potentially fatal infected bedsores.
Explanation:
By instructing the client to use the overbed trapeze to move, the nurse is reducing the risk of pressure ulcer development. Pressure ulcers, also known as bedsores or decubitus ulcers, occur as a result of constant, unrelieved pressure on specific bony parts of the body. This pressure restricts blood flow and leads to necrosis or tissue death.
Pressure ulcers are common in individuals who are immobilized for prolonged periods or who have debilitating conditions, like elderly patients. Using the overbed trapeze not only promotes movement, improving blood circulation, but also changes the areas of the body bearing weight, thereby reducing pressure in those areas and minimizing the risk of bedsore development.
Hospitals and long-term care facilities often have protocols in place to regularly relocate or position patients to avert pressure sores which could otherwise become infected and potentially fatal if not treated promptly by removing the necrotic tissue.
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