A nurse is caring for an elderly patient with a stage 3 pres… | 마이메르시 MyMerci
Adult Health
문제

A nurse is caring for an elderly patient with a stage 3 pressure injury on the sacrum. Which nursing intervention should be the highest priority to prevent further tissue damage and promote healing?

해설
The highest priority for a stage 3 pressure injury is to eliminate pressure through frequent repositioning and pressure-relieving devices to prevent further tissue damage and promote healing.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question assesses the priority nursing intervention for managing a Pressure injury (Pressure ulcer), specifically a Stage 3 injury on the sacrum. The core principle is that the primary cause of pressure injury development and progression is unrelieved pressure. Therefore, the most fundamental and highest priority intervention is always pressure relief. All other wound care measures (dressings, cleansing) are secondary if the underlying pressure is not addressed.

Answer Rationale: Key Point! The correct answer is ③ Implement a turning schedule every 2 hours and use pressure-relieving devices. This directly targets the etiology of the wound. A structured turning schedule (e.g., every 2 hours) and the use of specialized mattresses or overlays (pressure-relieving devices) are evidence-based, first-line interventions to redistribute pressure, prevent further ischemia, and create an environment conducive to healing.

Distractor Analysis:
• Watch out for confusion! ① Apply a hydrocolloid dressing and change it every 3 days: While a hydrocolloid dressing is appropriate for some Stage 3 wounds (creating a moist wound healing environment), it is a wound management intervention, not the priority cause-eliminating intervention. Dressing selection is important but comes after pressure relief.
• Watch out for confusion! ② Massage the area around the pressure injury to improve circulation: This is contraindicated. Massaging over or around a pressure injury, especially bony prominences, can cause shear and friction, damaging delicate capillaries and potentially worsening the tissue damage. Current guidelines explicitly advise against this practice.
• Watch out for confusion! ④ Clean the wound with hydrogen peroxide twice daily: This is incorrect and harmful. Hydrogen peroxide is cytotoxic and can damage healthy granulation tissue, delaying healing. Normal saline or prescribed wound cleansers are the standard for gentle, non-toxic wound irrigation.

Related Concepts: Remember the nursing process: Assessment (staging the ulcer) leads to a nursing diagnosis (e.g., Impaired Skin Integrity related to pressure). The planning and implementation must first address the related factor ("pressure") before other symptomatic treatments. The Braden Scale is used for risk assessment, and prevention is always paramount.

Concept Summary • Pressure Injury Staging (NPUAP): Stage 1 (Non-blanchable erythema), Stage 2 (Partial-thickness skin loss), Stage 3 (Full-thickness skin loss, subcutaneous fat visible), Stage 4 (Full-thickness skin and tissue loss with exposed bone/tendon/muscle).
• Core Etiology: Pressure → Ischemia → Tissue Necrosis. Contributing factors: Shear, Friction, Moisture.
• Priority Intervention: Relieve pressure (repositioning, pressure-redistributing surfaces).
• Wound Care Principle: Maintain a clean, moist environment for healing. Avoid cytotoxic agents (hydrogen peroxide, povidone-iodine full strength).
• Contraindicated Actions: Massaging reddened or ulcerated areas; using donut-shaped cushions (increases pressure on surrounding tissue).

Side-by-Side Comparison!
InterventionRationale & UsePrecautions/Contraindications
Turning Schedule (Q2H)Gold standard for pressure relief. Prevents prolonged ischemia.Must be documented and consistently followed. Use lift sheets to minimize shear.
Hydrocolloid DressingProvides moist wound healing; autolytic debridement; protects from contamination.Not for infected wounds or wounds with heavy exudate. Change per protocol, not on a rigid schedule if intact.
Wound Cleansing with Normal SalineGentle; non-cytotoxic; removes debris and surface bacteria.Use sufficient irrigation pressure (e.g., via syringe). Avoid drying the wound bed.

Anatomy, Physiology & Pharmacology Points • Pathophysiology: External pressure exceeding capillary closing pressure (approx. 32 mmHg) compresses blood vessels, leading to tissue ischemia, hypoxia, accumulation of metabolic waste, and ultimately cell death (necrosis). The sacrum is a high-risk area due to its bony prominence and weight-bearing in supine/sitting positions.
• Pharmacology Note: Topical antimicrobials (e.g., silver sulfadiazine) may be used for critically colonized or infected wounds, but are not first-line for clean pressure injuries. Systemic antibiotics are reserved for cellulitis, osteomyelitis, or sepsis.

Memory Tips • Priority Acronym: "Relieve Pressure First!" (RPF).
• Contraindication Mnemonic: "Hands Off Massage, Hold the Hydrogen Peroxide" (HOM HHP).
• Turning Schedule: Remember "Q2H" – it's the standard for at-risk patients.

High-Frequency NCLEX Topics Pressure injury care is a High Yield topic. The NCLEX frequently tests:
1. Identifying the correct stage from a description or image.
2. Selecting the priority or initial nursing action (almost always pressure relief).
3. Recognizing contraindicated actions (massage, donut cushions, harmful cleansers).
4. Knowing appropriate wound dressings for different stages.

Watch Out for Question Variations! • Instead of "highest priority," the question may ask for the "most appropriate" or "initial" action.
• The scenario may change the stage (e.g., Stage 1 vs. Stage 4) – the priority of pressure relief remains constant, but wound care specifics differ.
• The question may combine with nutritional support (e.g., need for protein, vitamin C, zinc) as a secondary priority for healing.
• It may test knowledge of specific pressure-relieving devices (e.g., low-air-loss mattress, foam overlay).

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are assigned to Mr. Johnson, an 82-year-old male with dementia and limited mobility, admitted for dehydration. During your shift assessment, you discover a Stage 3 pressure injury on his sacrum. The wound is approximately 4cm in diameter, with full-thickness skin loss, visible subcutaneous fat, and moderate serosanguinous drainage. No foul odor is noted.

Nursing Intervention Strategy:
1. Assessment & Documentation: Perform a comprehensive skin assessment. Document the pressure injury using the STAGE system, location, size (length, width, depth in cm), tissue type in wound bed (e.g., slough, granulation), exudate (amount, type, color), periwound skin condition, and presence of tunneling or undermining. Use a pressure injury risk assessment tool (Braden Scale) to quantify his ongoing risk.
2. Immediate Priority Action: Key Point! Initiate a turning and repositioning schedule immediately. Collaborate with nursing assistants to ensure Mr. Johnson is repositioned at least every 2 hours. Use a lift sheet to move him, avoiding dragging his skin (shear). Place him in a 30-degree lateral tilt position when side-lying to reduce pressure on the trochanter. Obtain an appropriate pressure-redistributing mattress (e.g., alternating pressure or high-specification foam mattress) per facility protocol.
3. Wound Care: After ensuring pressure relief is in place, proceed with wound care per the healthcare provider's orders or wound care protocol. This typically involves:
• Cleansing: Gently irrigate the wound with warm Normal Saline using a syringe and angiocath to provide safe pressure.
• Dressing: Apply a dressing that manages moisture (e.g., alginate or foam for moderate exudate, hydrocolloid for light exudate). Secure it without putting tension on the surrounding skin.
• Monitor for Infection: Assess for signs of infection (increased pain, erythema, warmth, purulent drainage, foul odor, fever).
4. Holistic Care & Education: Address nutritional status (consult dietitian for high-protein, high-calorie diet with vitamin C and zinc supplements). Maintain optimal hydration. Educate the family about the cause of the wound and the critical importance of the turning schedule, even if the patient is sleeping.

Patient Safety and Precautions:
• NEVER massage reddened or ulcerated areas.
• NEVER use donut-shaped cushions or rings.
• AVOID harsh antiseptics (hydrogen peroxide, iodine, Dakin's solution) for routine cleansing.
• Ensure heels are floated off the bed with pillows or heel protectors.
• Keep skin clean and dry; use moisture barrier creams in perineal area if incontinent.

Nursing Procedure & Medication Flow Wound Care Procedure (Simplified):
1. Perform hand hygiene and don clean gloves.
2. Gently remove old dressing; discard in biohazard waste.
3. Remove gloves, perform hand hygiene, don new sterile gloves.
4. Assess wound.
5. Irrigate with Normal Saline.
6. Pat dry surrounding skin (not the wound bed).
7. Apply prescribed topical agent or primary dressing.
8. Apply secondary dressing if needed. Secure.
9. Dispose of waste, remove gloves, perform hand hygiene.
10. Document findings and care provided.

A Word from Your Senior Nurse Pressure injuries are often called "never events" because they are largely preventable with excellent nursing care. Your vigilant assessment and relentless commitment to turning schedules are what protect your most vulnerable patients. In clinical practice, you'll be the one to spot that first non-blanchable redness. On the NCLEX, they are testing your foundational understanding that removing the cause (pressure) is always job #1. Remember, you are not just putting on a bandage; you are being a detective and an engineer—finding the problem and redesigning the patient's environment to solve it. That's powerful nursing!

핵심 개념

  • Pressure Injury (Pressure Ulcer) — 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.
  • Shear — A mechanical force parallel to the skin surface that causes stretching and tearing of blood vessels, contributing to pressure injury development (e.g., sliding down in bed).
  • Braden Scale — A validated tool used to assess a patient's risk for developing pressure injuries based on 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, creating a moist healing environment and facilitating autolytic debridement.
  • Normal Saline — A sterile 0.9% sodium chloride solution. It is isotonic and non-cytotoxic, making it the solution of choice for wound irrigation and cleansing.

마이메르시로 국가고시 완벽 대비

기출문제와 상세 해설을 무료로. 내 약점을 분석하고 진도를 관리하며 더 똑똑하게 공부하세요.

무료로 시작하기
App Store Google Play

학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.