A client with limited mobility has nonblanchable redness ove… | MyMerci
Mobility/ImmobilityBCC
Question
A client with limited mobility has nonblanchable redness over the sacrum. Which intervention is most appropriate?
1Massage the reddened area vigorously each shift.
2Place the client directly on the sacrum to reduce hip pressure.
3Reposition the client regularly and use pressure-reducing support surfaces.✓ Correct answer
4Apply adhesive tape tightly over the area to protect it.
Explanation
Nonblanchable redness suggests early pressure injury. Pressure should be relieved through repositioning, support surfaces, moisture control, nutrition support, and skin inspection. Massaging reddened tissue or applying tight tape can worsen injury.
In-depth explanation
Clinical Judgment Pressure injury prevention begins with removing pressure, not rubbing the damaged tissue.
Memory Tip Red that does not blanch: offload pressure.
Clinical scenario
Clinical Practice Guide Skin integrity care includes turning schedules, pressure redistribution, moisture management, nutrition, and daily inspection.
Caution Do not massage bony prominences with nonblanchable redness.
Key concepts
Pressure Injury — Localized skin or tissue damage caused by pressure or shear.
Nonblanchable Redness — Redness that does not turn white with pressure and suggests tissue injury.
Offloading — Removing pressure from an at-risk area.