A nurse is caring for a 65-year-old patient who has been on bed rest for 3 days following spinal surgery. During assessment, the nurse notes stage 1 pressure injury on the patient's sacrum. What is the most appropriate nursing intervention to prevent progression of this pressure injury?
1Apply a hydrocolloid dressing to the affected area
2Massage the reddened area gently to improve circulation
3Keep the area clean and dry with frequent position changes every 4 hours
4Implement a turning schedule every 2 hours and use pressure-relieving devices✓ 정답
해설
The most appropriate intervention is repositioning every 2 hours with pressure-relieving devices to prevent progression. Other options are less effective for stage 1 pressure injury.
Clinical Judgment
This question assesses the core principles of Pressure Injury Prevention. A Stage 1 Pressure Injury is a condition where the skin is intact but shows non-blanchable erythema, indicating that tissue damage has begun. The most important nursing intervention is eliminating the source of pressure. Option 4 presents a fundamental and comprehensive prevention strategy by combining repositioning (every 2 hours) with the use of pressure-relieving devices to eliminate sustained pressure and redistribute weight. In contrast, the other options are inappropriate interventions that only manage symptoms (Options 1, 3) or could even worsen the damage (Option 2).
Memory Tip:
Remember the TUP principle: Turn (repositioning), Use devices, Protect skin. For a Stage 1 pressure injury, Turn and Use devices are the most critical.
KR vs US
In Korea, the principle of repositioning every 2 hours for pressure injury prevention is the same, but in actual clinical settings, it may be difficult to adhere to due to staffing shortages. The US NGN emphasizes strict application of standard protocols (repositioning every 2 hours, use of specialized mattresses) based on Evidence-Based Practice. Also, 'Massage' is an outdated practice that is not recommended in Korea either.
Clinical Practice Guide
The goal of Stage 1 pressure ulcer management is to prevent progression. When repositioning, use a 30-degree lateral position, and immediately introduce a specialized mattress (e.g., air, foam, gel mattress). Skin inspection should be performed at every repositioning.
Caution
In SATA (Select All That Apply) questions, never select "Massage the reddened area." This is a harmful intervention that can further damage capillaries. Also, "every 4 hours" is too long an interval and is not effective for prevention.
Stage 1 Pressure Injury — Stage 1 pressure ulcer. The skin is intact but there is localized non-blanchable erythema. This is the early stage of tissue damage.
Pressure-Relieving Devices — Pressure-relieving devices. Special mattresses (air, foam, alternating pressure), cushions, heel protectors, etc., which distribute body weight to reduce localized pressure.
Non-blanchable Erythema — Non-blanching erythema. A condition where the redness does not disappear when pressed with a finger, indicating damage to capillaries deep in the dermis and a characteristic finding of stage 1 pressure ulcer.
Shearing Force — Shear force. A force that occurs when the torso slides while the skin remains fixed, stretching or tearing subcutaneous tissue and blood vessels, increasing the risk of pressure ulcer development.
Repositioning Schedule — Position change schedule. A plan to regularly reposition the patient to prevent pressure ulcers. The standard is every 2 hours, with a 30-degree lateral position recommended.