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.
Core Nursing ExplanationKey Concept Analysis: This question tests the fundamental nursing intervention for preventing the progression of a Stage 1 pressure injury. The core pathophysiology involves pressure, shear, and friction causing localized tissue ischemia. The primary goal is to relieve pressure and prevent further tissue damage.
Answer Rationale: Key Point! The cornerstone of pressure injury prevention and management is pressure redistribution. A turning schedule every 2 hours (or more frequently based on individual risk) is the standard of care. Using pressure-relieving devices (e.g., specialized mattresses, heel protectors) complements repositioning by minimizing pressure on bony prominences. This intervention directly addresses the root cause—prolonged pressure—and is the most appropriate first-line action for a Stage 1 injury.
Distractor Analysis:
Watch out for confusion! Option ① (Apply a hydrocolloid dressing): Hydrocolloid dressings are typically used for Stage 2 injuries (partial-thickness skin loss) or to protect fragile skin. For intact, non-blanchable erythema (Stage 1), the priority is pressure relief, not advanced dressings.
Watch out for confusion! Option ② (Massage the reddened area): This is an outdated and potentially harmful practice. Massaging an area of non-blanchable erythema can cause further damage to the microcirculation and underlying tissue. It is contraindicated.
Watch out for confusion! Option ③ (Keep clean/dry, reposition every 4 hours): While keeping the area clean and dry is important for skin integrity, repositioning every 4 hours is insufficient for a high-risk, immobile patient. The standard is every 2 hours (or even 1 hour for some patients) to effectively offload pressure.
Related Concepts: This scenario integrates knowledge of skin integrity, mobility, and postoperative care. Understanding the Braden Scale for predicting pressure injury risk is also crucial. The patient's age, surgery, and bed rest status place them at very high risk.
Concept Summary
Concept
Key Takeaway
Stage 1 Pressure Injury
Intact skin with non-blanchable redness. The tissue is ischemic but not broken.
Primary Intervention
Pressure relief via frequent repositioning (q2h) and pressure-redistributing surfaces.
Prevention & management of ALL stages of pressure injury. Gold standard.
Never inappropriate for prevention. Frequency may need to be increased.
Hydrocolloid Dressing
Stage 2 injuries (blister/abrasion), to protect skin, manage light exudate.
Stage 1 injury (intact skin). It doesn't address the core problem of pressure.
Massaging Reddened Skin
Never appropriate for non-blanchable erythema.
Stage 1 injury. Can cause shear and further tissue trauma.
Anatomy, Physiology & Pharmacology Points
Pathophysiology: Sustained pressure (> capillary closing pressure of ~32 mmHg) compresses blood vessels, leading to tissue ischemia, hypoxia, cell death, and eventual ulceration. The sacrum is a high-risk bony prominence.
Skin Assessment: Blanching is key. Press on the red area with a finger. If it turns white and then red again (blanches), it's reactive hyperemia. If it stays red (non-blanchable), it's a Stage 1 pressure injury.
Memory Tips
Mnemonic: "Turn for the Better": Think Q2 turns (every 2 hours) for pressure ulcer prevention.
Stage 1 = RED & STAYS RED: Non-blanchable erythema is the hallmark. Don't rub it!
Dressings are for open wounds: If the skin is intact (Stage 1), focus on pressure relief, not dressings.
High-Frequency NCLEX Topics
Pressure injury prevention is a Core NCLEX topic. Expect questions on:
Identifying stages of pressure injuries from descriptions or images.
Selecting the priority or most appropriate intervention (often repositioning).
Shift from "Prevent" to "Treat": The question might ask for the nursing action for a Stage 3 injury (full-thickness tissue loss). Answer would shift to include wound care (e.g., moist wound healing, debridement) in addition to pressure relief.
Prioritization: "Which client should the nurse see first?" A client with a new Stage 1 injury on bed rest might be prioritized over a stable chronic wound.
Patient Education: The question could ask what to teach a family member caring for an immobile patient at home (e.g., "Demonstrate how to reposition the patient every 2 hours").
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a surgical unit. Mr. Johnson, 65, is post-op day 3 from a lumbar laminectomy. He has been on strict bed rest. During your morning assessment, you notice a 3 cm area of persistent red discoloration on his sacrum that does not blanch when you press it. His skin is intact but warm to the touch.
Nursing Intervention Strategy:
Assessment & Documentation: Precisely document the finding: "Stage 1 pressure injury, sacrum, 3cm diameter area of non-blanchable erythema, skin intact." Use a pressure injury staging tool and document using the hospital's skin integrity flowsheet. Reassess the Braden Scale score (it will be low due to mobility).
Immediate Action (Planning & Implementation):
Repositioning Schedule: Implement a strict turning schedule. Log turns on the board: "Turn side-back-side q2h." Use pillows for positioning to keep pressure off the sacrum and other prominences (heels, trochanters).
Pressure-Relieving Surface:
Notify the charge nurse or wound care team to obtain a pressure-redistributing mattress (e.g., alternating pressure, high-spec foam). Place heel protectors on the patient.
Skin Care: Keep the area clean and dry. Use a pH-balanced skin cleanser. Apply a moisture barrier cream to protect from incontinence, but do not apply anything to the reddened area itself that could trap moisture or cause shear.
Nutritional Support: Collaborate with the dietitian. Ensure adequate protein and calorie intake to support tissue repair. Monitor albumin/prealbumin levels.
Evaluation: Reassess the area every shift. The goal is for the erythema to resolve (blanchable or disappear). If it worsens (skin breaks open), it becomes a Stage 2 injury, requiring a change in plan (e.g., consult wound care, consider a protective dressing).
Patient Safety and Precautions:
NEVER MASSAGE bony prominences or areas of non-blanchable redness.
Use a draw sheet or lift device to move the patient to avoid friction and shear, which are just as damaging as pressure.
Ensure the bed is flat when repositioning. Raising the head of the bed above 30 degrees increases shear forces on the sacrum.
Educate the patient (if able) and family on the importance of frequent position changes, even small shifts in weight.
Nursing Procedure & Medication FlowProcedure: Implementing a Turning Schedule
Assess: Identify all pressure points (sacrum, heels, elbows, scapulae, back of head, trochanters).
Plan: Create a turn clock (e.g., 2 am left side, 4 am back, 6 am right side, 8 am left side...).
Implement:
Gather assistance if needed.
Lower the bed rail. Use a draw sheet. Gently roll the patient onto their side, maintaining body alignment.
Support with pillows behind the back, between knees and ankles, and in front of the chest/abdomen.
Ensure the bottom arm is not trapped. Check tubing and lines.
Document: Time, position, skin condition, and patient tolerance.
A Word from Your Senior Nurse
"Pressure injuries are often called 'never events' because they are largely preventable with diligent nursing care. Finding that first spot of non-blanching redness is your critical cue to act. It's not just a task on a list—turning that patient is a powerful intervention that protects their skin, prevents pain, and avoids a long, complicated healing process. In clinicals and on the NCLEX, always go back to the basics: offload the pressure first! Your vigilance makes all the difference."
Pressure Injury — Localized damage to the skin and/or underlying soft tissue, usually over a bony prominence, due to intense and/or prolonged pressure or pressure in combination with shear.
Non-blanchable Erythema — Redness of intact skin that does not turn white (blanch) when pressed; the hallmark sign of a Stage 1 pressure injury.
Shear Force — A mechanical force parallel to the skin surface that causes stretching and tearing of blood vessels and tissue, contributing to pressure injury development (e.g., sliding down in bed).
Braden Scale — A validated tool used to predict a patient's risk for developing pressure injuries based on six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
Pressure Redistribution — The principle of using specialized support surfaces (mattresses, cushions) and frequent repositioning to minimize pressure on vulnerable areas of the body.