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:- 1AssessmentPerform 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.
- 2Planning & 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).
- 3Patient & Family EducationTeach 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."