A nurse is caring for a 78-year-old patient who has been bedridden for 10 days following hip fracture surgery. The patient has developed a stage 2 pressure injury on the sacrum. Which nursing intervention should be the priority to prevent further deterioration of the pressure injury?

The priority is to eliminate pressure through repositioning every 2 hours and pressure-redistributing surfaces, addressing the root cause. Other options are less effective or contraindicated for stage 2 pressure injury.

Core Nursing Explanation Key Concept Analysis: This question tests the fundamental principle of pressure injury (pressure ulcer) management. The core pathophysiology is that unrelieved pressure over a bony prominence leads to tissue ischemia and necrosis. For a patient who is bedridden post-surgery, the primary cause of the injury is sustained pressure and shear forces. Therefore, the most critical intervention must address this root cause.

Answer Rationale: Key Point! The single most important intervention for both preventing and treating pressure injuries is pressure redistribution and relief. Option ④ directly targets this by implementing repositioning every 2 hours (to relieve pressure) and using pressure-redistributing surfaces (like specialized mattresses or overlays). This is the first step in the nursing process for any pressure injury, regardless of stage. Without addressing pressure, no other wound care intervention will be effective.

Distractor Analysis:
Watch out for confusion! Option ①: While a hydrocolloid dressing can be appropriate for a clean Stage 2 injury by creating a moist wound environment, it is a secondary intervention. The priority is pressure relief. Furthermore, changing it every 7 days is a guideline, but the dressing should be changed if it leaks or detaches.
Watch out for confusion! Option ②: Massaging the area around the injury is contraindicated. Massaging over or near a pressure injury can cause further tissue damage by shearing fragile capillaries and deepening the injury. This is an outdated practice that should be avoided.
Watch out for confusion! Option ③: Keeping a wound "dry and exposed to air" is an outdated concept for most wound healing. Modern wound care follows the principle of moist wound healing, which promotes faster epithelialization. A dry environment leads to cell death and scab formation, which impedes healing.

Related Concepts: Pressure injury staging (NPUAP classification), the Braden Scale for predicting pressure injury risk, and the principles of moist wound healing are all interconnected. Remember: Relieve pressure first, then manage the wound.

Concept Summary

Concept	Key Takeaway
Pressure Injury Etiology	Caused by pressure, shear, friction, and moisture. Pressure is the primary culprit.
Nursing Priority	Pressure relief and redistribution are ALWAYS the first-line interventions.
Stage 2 Pressure Injury	Partial-thickness skin loss with exposed dermis. Presents as a shallow open ulcer or intact/ruptured blister.
Contraindicated Actions	Do not massage reddened or damaged skin. Do not use donut-shaped cushions.
Wound Bed Preparation	Follow TIME principle: Tissue management, Infection/Inflammation control, Moisture balance, Edge advancement.

Side-by-Side Comparison!

Intervention	Appropriate Use	Inappropriate Use / Caution
Repositioning (Q2H)	Fundamental for all at-risk or injured patients. Use 30-degree lateral tilt.	Lifting, not dragging, to prevent shear. Use trapeze bar if allowed.
Hydrocolloid Dressing	For clean Stage 1-2 injuries. Provides moist environment and autolytic debridement.	Not for infected wounds or wounds with heavy exudate. Priority comes after pressure relief.
Massage	Not recommended for pressure injury care.	Contraindicated. Can cause microvascular damage and shear injury.
Air Exposure	Rarely used. May be for superficial skin tears with minimal exudate.	Outdated for pressure injuries. Delays healing by creating a dry, necrotic wound bed.

Anatomy, Physiology & Pharmacology Points The sacrum is a common site for pressure injuries in bedridden patients due to its prominent bony structure and the significant pressure exerted when lying supine. The pathophysiological sequence is: Pressure → Capillary occlusion → Tissue ischemia → Necrosis → Ulceration. Capillaries collapse at pressures exceeding 32 mmHg. Standard hospital mattresses can generate pressures over 100 mmHg at the sacrum, far exceeding capillary closing pressure.

Memory Tips Acronym: PRESS
Position change Q2H
Relieve pressure (special surfaces)
Evaluate skin daily
Shear and friction prevention (lift, don't drag)
Support nutrition (protein, vitamins)

Remember: "First, get the pressure off!" No dressing can heal a wound that is continuously being crushed.

High-Frequency NCLEX Topics Pressure injury prevention and staging is a Core NCLEX topic. You will be tested on: 1. Identifying correct vs. incorrect nursing interventions (like massaging). 2. Prioritizing care (pressure relief first). 3. Matching wound characteristics to the correct stage (I-IV, Unstageable, Deep Tissue Injury). 4. Understanding the use of risk assessment tools like the Braden Scale.

Watch Out for Question Variations! * Instead of asking for the priority intervention, a question might ask: "The nurse is developing a care plan for a patient at risk for pressure injuries. Which finding by the nurse indicates the plan is effective?" Correct answer: "Skin remains intact over bony prominences." * The scenario could shift to a Stage 3 or 4 injury with tunneling. The priority of pressure relief remains the same, but wound care interventions become more complex (e.g., packing with saline-moistened gauze). * A question might test contraindications directly: "Which action by a nursing assistant requires immediate intervention by the nurse?" Correct answer: "Massaging a reddened area on the patient's heel."

Nursing Clinical Practice Guide Clinical Scenario: You are assigned to Mr. Johnson, a 78-year-old with a new Stage 2 sacral pressure injury. He is alert but fatigued and in pain from his recent hip surgery. He finds turning uncomfortable.

Nursing Intervention Strategy: 1. Assessment: Perform a comprehensive skin assessment using the Braden Scale. Document the injury: size, depth, color of wound bed and edges, exudate, odor. Assess pain level associated with the wound and repositioning. 2. Planning & Implementation: * Collaborate with the wound care nurse if available. * Immediate Action: Place the patient on a pressure-redistributing mattress (e.g., low-air-loss, alternating pressure). Document the intervention. * Implement a turning schedule every 2 hours (even at night). Use a clock or timer. Log positions. * For the wound: Cleanse with normal saline or a wound cleanser. Apply an appropriate secondary dressing like a hydrocolloid or foam to maintain a moist environment. Secure it well to prevent shear from clothing/bedding. * Manage pain: Administer prescribed analgesics 30 minutes before planned repositioning to increase adherence. * Optimize nutrition: Consult a dietitian. Ensure adequate protein (1.2-1.5 g/kg/day), calories, and vitamins (especially Vitamin C and Zinc). 3. Patient & Family Education: Teach the patient and family the purpose of frequent turns ("to take the pressure off the sore spot"). Encourage them to remind staff about the turning schedule. Teach them to report any increase in pain, redness, swelling, or foul odor.

Patient Safety and Precautions: * NEVER massage reddened or broken skin. * NEVER use donut-shaped cushions (they increase pressure on surrounding tissue). * When repositioning, lift the patient using a draw sheet or trapeze bar; never drag them across the sheets (causes shear). * Monitor for signs of infection: Increased redness, warmth, swelling, purulent exudate, foul odor, fever, or elevated WBC.

Nursing Procedure & Medication Flow Wound Dressing Change Procedure: 1. Perform hand hygiene and don clean gloves. 2. Gently remove old dressing. Note characteristics of exudate on dressing. 3. Discard gloves, perform hand hygiene again. 4. Don sterile gloves. 5. Cleanse wound from center outward with sterile normal saline and gauze. 6. Pat surrounding skin dry. 7. Apply prescribed dressing. 8. Secure dressing. Label with date, time, and initials. 9. Dispose of waste, remove gloves, perform hand hygiene. 10. Document assessment and procedure.

Repositioning Flow: Supine → 30° Right Lateral Tilt (support with pillows) → Supine → 30° Left Lateral Tilt. Avoid 90° side-lying directly on the trochanter. Use pillows between knees and ankles.

A Word from Your Senior Nurse "In the real world, pressure injuries are often called 'never events' because they are largely preventable with diligent nursing care. That 2-hour turn might feel like a chore at 2 AM, but you are literally saving your patient's skin and preventing months of painful healing. Be the nurse who champions the turning schedule, who questions the use of a donut cushion, and who meticulously documents skin changes. Your vigilance is the patient's first and best defense. For the NCLEX, always remember the hierarchy: Remove the cause first (pressure), then treat the wound. If you remember that, you'll ace these questions."