Nursing Clinical Practice Guide
Clinical Scenario: You are the day-shift nurse for Mr. Johnson, a 78-year-old man who underwent a right hip hemiarthroplasty (hip fracture surgery) 5 days ago. He has been on bed rest with limited mobility. During your morning assessment, you logroll him to inspect his skin and find a persistent red patch over his coccyx that does not fade when you press your finger on it.
Nursing Intervention Strategy:- 1Assessment & DocumentationDocument the finding precisely: "3x4 cm area of non-blanching erythema over coccyx. Skin intact. Patient denies pain at site." Measure and photograph if facility policy allows. Calculate his Braden Scale score (likely very low due to mobility, moisture, etc.).
- 2Immediate ActionDo not massage the area! Massaging ischemic tissue can cause further microvascular damage. Implement strict, scheduled turning and repositioning (at least every 2 hours). Use pillows and positioning devices to keep pressure off the coccyx. Ensure he is placed on a pressure-redistributing mattress (e.g., foam overlay, alternating pressure mattress).
- 3Ongoing Care & CollaborationNotify the primary care provider or wound care nurse. Educate the patient and family on the importance of frequent repositioning. Manage incontinence meticulously to keep skin clean and dry. Optimize nutrition (adequate protein, vitamins C & A, zinc) to support tissue repair.
Patient Safety and Precautions: Never use donut-shaped cushions, as they can increase pressure on the surrounding tissue and impair blood flow. Assess for pain, but note that Stage 1 injuries may not be painful, especially in patients with sensory impairment.
Nursing Procedure & Medication Flow
Skin Assessment Procedure:
1. Ensure privacy and explain the procedure.
2. With assistance, logroll the patient to expose the sacrum, coccyx, and heels.
3. In good lighting, visually inspect and gently palpate bony prominences.
4. Perform the blanch test: Press a fingertip firmly on the reddened area for 3 seconds, then release. Observe if redness fades (blanches) and returns.
5. Document findings using standardized terminology (blanching vs. non-blanching, location, size, color, tissue integrity).
A Word from Your Senior Nurse
"In the real world, that non-blanching red spot is your patient's skin crying out for help. Catching it at Stage 1 is a nursing win—it means you have a chance to stop it in its tracks. Your vigilant assessment and prompt action are what prevent a simple red spot from becoming a deep, painful wound that increases infection risk, hospital stay, and suffering. On the NCLEX, they test this because it's non-negotiable in practice. Always think: 'Blanch or not blanch?' That's the question that separates normal redness from the start of a pressure injury."