A client has a reddened area on his right heel.
What is the best intervention by the nurse to prevent further skin and tissue breakdown?

The best intervention by the nurse to prevent further skin and tissue breakdown on a reddened area on a client’s right heel is to relieve pressure from the right heel1.

Heels are particularly vulnerable to skin breakdown and when patients lie supine, all of the pressure of their lower legs and feet rest on the heels1.

Preventing heel ulcers primarily involves the use of simple devices, like pillows and offloading devices, to protect delicate heels1.

Choice A is not correct because documenting the reddened area alone will not prevent further skin and tissue breakdown.

Choice B is not correct because asking the client how the area became reddened alone will not prevent further skin and tissue breakdown.

Choice C is not correct because assessing the client’s diet alone will not prevent further skin and tissue breakdown.

A surgical sponge left in a client’s incision is a “never event”.

A “never event” is a serious, largely preventable safety incident that should not occur if the available preventative measures are implemented1.

These events include things like wrong-site surgery or foreign objects left in a person’s body after an operation2.

Choice A is incorrect because no blood incompatibility during a blood transfusion is not a “never event”.

Choice C is incorrect because a client falling in their own home is not a “never event”.

Choice D is incorrect because inserting a urinary catheter before surgery is not a “never event”.