A nurse is assessing a 78-year-old patient who has been bedridden for 5 days following hip fracture surgery. Which assessment finding would be the MOST concerning for pressure injury development?

For a bedridden older adult, differentiating reactive hyperemia from a Stage 1 pressure injury is critical for timely intervention. Use this guide to standardize your skin assessment.

Press your fingertip firmly over the area of erythema for 3 seconds, then release.

• Blanchable (Reactive Hyperemia): The skin turns white under your finger and redness returns immediately upon release. This is a normal response to pressure and typically resolves within 30-60 minutes of offloading.
• Non-blanchable (Stage 1 Pressure Injury): The redness persists and does not turn white under pressure. This indicates blood has leaked from damaged capillaries into the tissue and is the defining sign of a Stage 1 injury.

In addition to blanchability, evaluate the following to confirm a Stage 1 injury versus other skin changes:

• Temperature: The area may feel warmer or cooler compared to surrounding skin. A slight temperature change alone is a subtle cue, but combined with non-blanchable erythema, it strengthens the diagnosis.
• Consistency: The tissue may feel boggy or firmer than the adjacent area due to underlying edema or induration.
• Sensation: The patient may report pain, itching, or burning at the site before visible changes appear. Always ask.

Upon identifying non-blanchable erythema, escalate preventive measures immediately to halt progression:

1. Strict Offloading: Reposition the patient at least every 2 hours using a written schedule. Ensure the coccyx is completely free of pressure; use pillows or wedges to maintain a 30-degree lateral tilt.
2. Surface Upgrade: Initiate a high-specification reactive foam mattress or an active alternating pressure surface if available. Do not use donut-type devices, which can cause venous congestion.
3. Skin Protection: Apply a barrier film or a thin hydrocolloid dressing over the intact erythematous area to reduce friction and shear forces.
4. Documentation: Document the exact location, size (length x width), color, and surrounding skin condition. Reassess at least every 8 hours.

Mild skin dryness and flaking on the lower extremities reflect a chronic impairment in barrier function common in aging skin. This is managed with emollients and hydration. It is not an acute ischemic event and should not be confused with a pressure injury over a bony prominence.