A nurse is caring for an elderly client with limited mobility who has developed a stage 2 pressure ulcer on the sacral area. Which nursing intervention should be the priority?
1Implement a turning schedule every 2 hours to relieve pressure on bony prominences✓ 정답
2Apply a hydrocolloid dressing to the pressure ulcer site
3Increase protein intake to 1.5 g/kg body weight daily
4Massage the reddened areas around the pressure ulcer
해설
Pressure relief through regular repositioning every 2 hours is the priority to address the root cause of pressure and prevent further tissue damage. Other interventions like dressings, nutrition, and massage are secondary without pressure relief.
Core Nursing Explanation
This question assesses the priority nursing intervention for managing a Pressure ulcer (also known as a pressure injury). The core principle is the Nursing Process and the concept of Key Point!addressing the root cause of a problem first. The patient is elderly with limited mobility and has a Stage 2 pressure ulcer, indicating partial-thickness skin loss.
Key Concept Analysis: The primary etiology of a pressure ulcer is unrelieved pressure over a bony prominence, leading to ischemia and tissue necrosis. All other interventions (wound care, nutrition) are supportive but are ineffective if the source of pressure is not removed. The Braden Scale is a key tool for predicting pressure ulcer risk, with mobility and activity being major components.
Answer Rationale: Key Point! The priority is to stop the ongoing tissue damage. Implementing a turning schedule every 2 hours directly addresses the causative factor—pressure. This is a foundational, non-negotiable intervention in pressure ulcer prevention and management. It aligns with the principle of pressure redistribution.
Distractor Analysis:
- Watch out for confusion! While applying a Hydrocolloid dressing (Option 2) is a correct and important intervention for a Stage 2 ulcer (providing a moist wound environment and protecting from shear/friction), it is a secondary intervention. Dressing the wound is futile if pressure on the area continues.
- Increasing Protein intake (Option 3) is crucial for wound healing, as protein is needed for tissue repair. However, optimizing nutrition is a supportive, long-term strategy and does not immediately stop the mechanical damage.
- Watch out for confusion! Massaging reddened areas (Option 4) is contraindicated. Massage can cause further damage to the delicate capillaries in the compromised tissue (blanching vs. non-blanching erythema). This is an outdated practice that should be avoided.
Related Concepts: This question integrates fundamentals of Gerontological nursing, Wound care, and patient safety. Remember the hierarchy of care: First, remove the cause (pressure); second, provide local wound care; third, support systemic healing (nutrition, hydration).
Concept Summary
- Etiology: Pressure + Shear/Friction + Moisture → Ischemia → Tissue Necrosis.
- Staging (NPUAP Classification): Stage 1: Non-blanchable erythema; Stage 2: Partial-thickness skin loss; Stage 3: Full-thickness skin loss; Stage 4: Full-thickness tissue loss with exposed bone/tendon.
- Priority Intervention: Pressure relief via repositioning (q2h), use of pressure-relieving devices (specialty mattresses).
- Supportive Care: Moist wound healing with appropriate dressings, nutritional support (protein, vitamins A & C, zinc), meticulous skin care, and patient/family education.
Side-by-Side Comparison!
Intervention
Purpose/Rationale
Priority Level
Turning Schedule (q2h)
Addresses the root cause (pressure); prevents further injury.
FIRST PRIORITY
Appropriate Wound Dressing
Manages the existing wound; promotes moist healing environment.
Secondary (after pressure relief)
Nutritional Support
Provides substrates (protein) for tissue repair and immune function.
Tertiary (supportive/long-term)
Skin Assessment & Care
Prevents breakdown in other areas; monitors for complications.
Ongoing/Concurrent
Anatomy, Physiology & Pharmacology Points
- Pathophysiology: Sustained pressure (>32 mmHg) exceeds capillary closing pressure, blocking blood flow. Ischemia begins within 2 hours, leading to cell death.
- Bony Prominences: Sacrum, heels, ischial tuberosities, trochanters, elbows, and occiput are most vulnerable.
- Pharmacology (Supportive): Vitamin C supplements (collagen synthesis), Zinc supplements (cell proliferation). Analgesics (e.g., acetaminophen) may be needed for pain management during dressing changes.
Memory Tips
- Mnemonic for Pressure Ulcer Prevention: "PRESS"
- Position changes (q2h)
- Relieve pressure (specialty surfaces)
- Elevate heels off bed
- Skin inspection daily
- Support nutrition & hydration
- Rule of Thumb: "If the pressure isn't off, the wound won't get better." Always think cause first.
High-Frequency NCLEX Topics
Pressure ulcers are a Core NCLEX topic, often tested on:
1. Priority Setting: Identifying the first/nursing action (always pressure relief).
2. Staging: Recognizing descriptions of Stage 1-4 ulcers.
3. Contraindications: Knowing what NOT to do (e.g., don't massage, don't use heat lamps, don't use donut rings).
4. Risk Assessment: Knowing the components of the Braden Scale.
Watch Out for Question Variations!
- Instead of asking for the priority intervention, the question might ask: "The nurse is teaching a family member about home care for a patient with a pressure ulcer. Which statement by the family member indicates a need for further teaching?" (Correct answer would be something like, "I will massage the red area to improve circulation.").
- The scenario could shift to a post-operative or ICU patient, testing the same principle in a different context.
- Questions may combine pressure ulcers with other comorbidities like Diabetes mellitus (DM) or Peripheral vascular disease (PVD), emphasizing the need for meticulous assessment and slower healing.
Nursing Clinical Practice GuideClinical Scenario: You are assigned to Mr. Johnson, an 82-year-old male admitted for pneumonia. He is weak, fatigued, and spends most of the day in bed. During your morning assessment, you discover a 3 cm x 2 cm area on his sacrum with a shallow open crater and a red wound bed. The surrounding skin is red and warm to touch. You document this as a suspected Stage 2 pressure ulcer.Nursing Intervention Strategy:
1AssessmentComplete a full skin assessment. Use the Braden Scale to score his risk (likely very high). Measure and photograph the wound (per facility policy). Assess pain (using a pain scale).
2Immediate Action (Priority)Reposition the patient immediately off the sacral area. Place him in a 30-degree lateral tilt position. Initiate a turning schedule in the care plan: "Turn and reposition at least every 2 hours." Use pillows for positioning.
3Pressure RedistributionCollaborate with the team to obtain a pressure-redistributing mattress (e.g., foam, alternating air, low-air-loss).
4Wound CareAfter ensuring pressure is relieved, clean the wound with normal saline. Apply a hydrocolloid or foam dressing as per protocol to maintain a moist environment. Change dressing according to manufacturer guidelines or when soiled.
5Systemic SupportConsult dietary services. Ensure his diet is high in protein (e.g., eggs, poultry, supplements). Monitor hydration status.
6Education & EvaluationEducate the patient (if alert) and family on the importance of turning. Evaluate the wound weekly for signs of healing (decreased size, granulation tissue) or deterioration (increased size, odor, exudate).
Patient Safety and Precautions:
1NEVERmassage reddened or bony areas.
2NEVERuse donut-shaped cushions (they increase pressure on surrounding tissue).
- Avoid dragging the patient across sheets (causes shear). Use a lift sheet.
- Keep skin clean and dry. Use moisture-barrier creams for incontinence.
- Heels must be floated off the bed using pillows under the calves.
Nursing Procedure & Medication FlowProcedure: Implementing a Turning Schedule
1. Gather supplies: pillows, lift sheet, pain medication if needed before moving.
2. Explain the procedure to the patient.
3. Enlist help if needed (for safe patient handling).
4. Using the lift sheet, gently turn the patient to a 30-degree side-lying position.
5. Support the back with pillows. Place a pillow between the knees to prevent pressure.
6. Ensure the heels are elevated.
7. Document: Time, position, skin condition, patient tolerance.
8. Set a timer or use the electronic health record (EHR) alert for the next turn.Medication/Wound Care Flow:
1CleansingUse normal saline or prescribed wound cleanser. Gently irrigate; don't scrub.
2Dressing ApplicationApply dressing without wrinkles. Extend it 1-2 inches beyond the wound edges.
3Pain ManagementAdminister prescribed analgesic (e.g., acetaminophen) 30 minutes before a scheduled dressing change if the patient reports pain.
A Word from Your Senior Nurse
"Nursing is not just about carrying out physician orders — it's about being the frontline guardian for your patients! In clinical practice, recognizing subtle changes in a patient's skin early can prevent a Stage 1 ulcer from progressing to a Stage 4. That turning schedule isn't just a task on a checklist; it's a lifeline for their tissue. When studying for your boards, don't just memorize 'turn q2h' — connect it to the physiology. Understand that you're restoring blood flow to starving cells. That mindset will not only earn you a great score on the NCLEX but will make you a truly confident, professional nurse who prevents harm every single shift!"
Pressure Ulcer (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.
Braden Scale — A validated tool used to assess a patient's risk for developing pressure ulcers. It scores six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
Hydrocolloid Dressing — An occlusive or semi-occlusive wafer dressing that interacts with wound exudate to form a gel, maintaining a moist wound environment. Used for Stage 2 and some Stage 3 pressure ulcers.
Shear — A mechanical force that occurs when tissue layers slide over one another, stretching and tearing blood vessels. A major contributing factor to pressure ulcer development, often happening when a patient slides down in bed.
Non-blanchable Erythema — Redness of the skin that does not turn white (blanch) when pressure is applied. This is the hallmark sign of a Stage 1 pressure ulcer, indicating compromised blood flow.