Basic Care and Comfort

Reposition at least every 2 hours in bed (more often if skin shows redness), and pair turning with a pressure-redistributing surface, clean dry skin, and adequate protein, calories, and fluids.

Stage 1 is intact skin with a localized area of nonblanchable erythema. Stage 2 is partial-thickness skin loss with exposed dermis: a pink or red moist wound bed or an intact or ruptured serum-filled blister, with no visible fat.

Stage 3 is full-thickness skin loss in which subcutaneous fat may be visible (slough, eschar, undermining, or tunneling may be present). Stage 4 is full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone.

Cardiovascular: venous thromboembolism and orthostatic hypotension. Respiratory: atelectasis and pneumonia. Skin: pressure injury. GI: constipation. Musculoskeletal: atrophy, contractures, and bone demineralization. Urinary: stasis, calculi, and infection.

Active ROM is performed by the client; passive ROM is performed by the nurse or therapist moving the joint for a client who cannot. Both maintain joint mobility and prevent contractures; move each joint only to the point of resistance, never to pain.

Hold the cane in the hand on the strong (unaffected) side. Advance the cane together with the weak (affected) leg, then step through with the strong leg. This widens the base of support and offloads the weak leg.