A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate?

Choice A rationale Immobilized patients with spinal cord injuries require frequent repositioning to mitigate prolonged pressure on vascular structures. A four hour interval is insufficient to prevent tissue ischemia; standard practice dictates turning at least every two hours. Normal capillary closing pressure is approximately 32 mmHg, and exceeding this for four hours leads to irreversible cellular hypoxia and subsequent stage one pressure injury development in paralyzed individuals. Choice B rationale Massaging erythematous areas over bony prominences is contraindicated because it causes deep tissue trauma. Erythema indicates that the inflammatory process and microvascular compromise are already present. Friction and pressure from massage further damage fragile capillaries and subcutaneous tissues, accelerating the transition from blanchable redness to non-blanchable tissue necrosis. This action decreases the structural integrity of the skin rather than promoting healthy circulation. Choice C rationale Suspending the heels using pillows, known as floating, is a critical intervention because the calcaneus is a high risk area with minimal subcutaneous cushioning. By eliminating direct contact with the mattress, the nurse prevents localized pressure from exceeding arterial capillary pressure. This ensures that the skin remains intact despite the loss of sensory perception and motor function typical in patients suffering from permanent spinal cord paralysis. Choice D rationale Using powder to keep skin dry is outdated and potentially harmful. Powders can clump when exposed to perspiration or moisture, creating abrasive particles that increase friction and shear against the epidermal layer. Furthermore, inhaled powder particles pose a respiratory risk. Modern wound care emphasizes using pH balanced moisture barriers or specialized films rather than powders to maintain the skin acid mantle and prevent maceration. Choice E rationale Excessive moisture from perspiration, wound drainage, or incontinence leads to skin maceration, which softens the stratum corneum and reduces its tensile strength. A softened epidermal barrier is significantly more susceptible to breakdown from friction and shearing forces during movement. Minimizing moisture exposure through frequent cleansing and absorbent pads preserves the integumentary system integrity, preventing the chemical and mechanical erosion of the skin surface.