A nurse is caring for an elderly client with limited mobility who has developed a stage 2 pressure ulcer on the sacral area. Which nursing intervention should be the priority?
1Implement a turning schedule every 2 hours to relieve pressure on bony prominences✓ 정답
2Apply a hydrocolloid dressing to the pressure ulcer site to promote healing
3Increase protein intake to 1.5 g/kg body weight daily for tissue repair
4Massage the reddened areas around the pressure ulcer to improve circulation
해설
Pressure relief through regular repositioning every 2 hours is the priority to address the root cause of pressure and prevent further tissue damage. Other interventions like dressings, nutrition, and massage are secondary without pressure relief.
Understanding the Priority for a Stage 2 Pressure Ulcer
When prioritizing care for a client with a stage 2 pressure ulcer, the nurse must address the root cause of the injury before focusing on local wound care or supportive therapies. A stage 2 ulcer involves partial-thickness skin loss with exposed dermis, presenting as a shallow open ulcer with a red-pink wound bed. The primary etiological factor is unrelieved pressure, particularly over bony prominences like the sacrum.
The priority intervention is to relieve pressure at the site. A systematic review on pressure ulcer prevention in bedridden patients identified repositioning as a core element of multidimensional intervention pathways, emphasizing that targeted preventive measures must directly counteract the mechanism of injury [1]. Without pressure relief, tissue ischemia persists, and the ulcer will inevitably deepen despite any topical treatment.
Why Option 1 is Correct
Implementing a turning schedule every 2 hours directly addresses the pathophysiological process of pressure injury formation. Sustained pressure compresses capillaries, reducing tissue perfusion below the critical closing pressure. This leads to ischemia, hypoxia, and eventual cell necrosis. A quality improvement initiative in a low-resource setting demonstrated that a structured turning protocol using a Turning Clock Tool significantly reduced the occurrence and severity of pressure injuries in high-risk, immobile patients [2]. Similarly, an ICU-specific quality improvement process that focused on patient turning and repositioning was developed in direct response to a sudden increase in sacral hospital-acquired pressure injuries, confirming that optimizing repositioning practices is the foundational preventive and therapeutic strategy [3]. While a study on paraplegic patients noted that conventional 2-hour turning has limitations and can be enhanced with interface pressure monitoring, it still validates turning as the standard, non-negotiable baseline intervention [4]. For a client with an existing stage 2 injury, this action halts the causative insult and allows the body's healing mechanisms to function.
Why the Other Options are Not the Priority
- Option 2: Apply a hydrocolloid dressing. A hydrocolloid dressing is an appropriate local wound care choice for a stage 2 ulcer to maintain a moist wound environment and promote healing. However, it is a secondary intervention. Applying a dressing without first eliminating the source of pressure is ineffective, as the tissue beneath the dressing will continue to be subjected to ischemic forces, leading to wound deterioration.
- Option 3: Increase protein intake to 1.5 g/kg/day. Adequate nutrition, particularly protein, is essential for tissue repair and is a key supportive measure in pressure ulcer management. While this is a vital component of the care plan, it addresses a systemic factor that supports healing over time. It does not immediately halt the ongoing mechanical trauma at the tissue level, making it a lower priority than pressure redistribution.
- Option 4: Massage the reddened areas. Massaging reddened or bony prominence areas is contraindicated in modern pressure ulcer care. The reddened area represents reactive hyperemia from ischemia, and massage can cause further damage to fragile capillaries and subcutaneous tissues, potentially converting a deep tissue injury or stage 1 ulcer into a deeper, more serious wound. This intervention is harmful and should never be performed.
The clinical reasoning framework here follows the principle of addressing the cause before the symptom. The systematic review highlights that effective interventions are built on core pathways that first mitigate the source of injury—sustained pressure [1]. Therefore, repositioning the client to relieve pressure on the sacrum is the immediate and highest-priority nursing action to prevent the progression of the stage 2 ulcer.
References (research sources)
[1]
Prevention and Care of Pressure Ulcers in Long-Term Bedridden Adult and Older Adult Patients in the Community: A Systematic Review.Meta-analysis/systematic reviewMeng L, Banharak S, Sommana C, Ransinyo K, Cheumnok W, Tian J. (2026) · DOI: 10.2147/tcrm.s592581
[2]
Quality education initiative to reduce pressure ulcers in high-risk-admitted patients in low-resource settings.Research articleKhattak AF, Hussain S, Ahmad B, Khattak M, Afridi WV, Khan B. (2026) · DOI: 10.1136/bmjoq-2025-003722
[3]
Implementation of a unit-specific quality improvement process for prevention of hospital-acquired pressure injuries.Research articleKern BK. (2025) · DOI: 10.1136/bmjoq-2025-003379
[4]
Effectiveness of skin interface pressure and temperature monitoring for pressure injury prevention in paraplegic patients: a comparative study.Research articleMiao A, Lin C, Ni Y, Yin S, Lv C, Huang H, Jiang X, Zhou H. (2025) · DOI: 10.3389/fpubh.2025.1521948
Clinical Practice Guide: Pressure Ulcer Prevention & Management
For an elderly client with limited mobility and a stage 2 sacral pressure ulcer, the immediate nursing priority is to eliminate the source of pressure to prevent further tissue damage. All other interventions are secondary.
Primary Intervention: Repositioning
Implement a strict turning schedule every 2 hours, including during the night.
Use a written turning clock or electronic reminder to ensure adherence.
Position the client using pillows or wedges to maintain a 30-degree lateral tilt, avoiding direct pressure on the sacrum and trochanters.
Document each position change and skin assessment findings.
Supportive Interventions (Initiate After Pressure Relief)
Wound Care: Cleanse the stage 2 ulcer with normal saline and apply a hydrocolloid or foam dressing to maintain a moist wound environment.
Nutritional Support: Collaborate with a dietitian to increase protein intake to 1.25-1.5 g/kg/day and ensure adequate hydration and calorie intake.
Skin Protection: Use barrier creams on periwound skin and moisture-wicking underpads to manage incontinence.
Actions to Avoid
Do not massage reddened or bony areas; this can cause deep tissue injury from damaged capillaries.
Avoid donut-type cushions, which can increase venous congestion and ischemia at the wound edge.
Do not rely solely on support surfaces without a manual repositioning schedule.
Priority is based on addressing the etiology: unrelieved pressure causes capillary occlusion and tissue ischemia. Repositioning restores perfusion and halts injury progression.
Stage 2 Pressure Ulcer — Partial-thickness skin loss involving the epidermis and dermis, presenting as a shallow open ulcer with a red-pink wound bed without slough.
Pressure Relief — The primary intervention for pressure injuries, achieved through regular repositioning to restore capillary blood flow and prevent tissue ischemia.
Tissue Ischemia — Reduced blood flow to tissues caused by sustained external pressure exceeding capillary closing pressure, leading to hypoxia and cell death.