A nurse is caring for an 82-year-old patient who has been bedridden for 2 weeks following hip fracture surgery and has developed a stage 3 pressure injury on the sacrum measuring 4 cm × 3 cm with visible subcutaneous tissue and moderate exudate. Which nursing intervention should be the highest priority to prevent further tissue damage and promote healing?
An 82-year-old patient has been bedridden for 2 weeks following hip fracture surgery and has developed a stage 3 pressure injury on the sacrum measuring 4 cm × 3 cm with visible subcutaneous tissue and moderate exudate.
1Apply a hydrocolloid dressing and change it every 3 days
2Position the patient on the affected area for short periods to promote circulation
3Cleanse the wound with hydrogen peroxide twice daily
4Implement a turning schedule every 2 hours and use pressure-redistributing surfaces✓ 정답
해설
The highest priority is implementing a turning schedule every 2 hours with pressure-redistributing surfaces to relieve pressure, the primary cause of tissue damage in pressure injuries. Other interventions like dressings or cleansing are secondary without pressure relief.
Core Nursing ExplanationKey Concept Analysis: This question tests the fundamental principle of pressure injury (pressure ulcer) management. The core pathophysiology is that sustained pressure, especially over bony prominences like the sacrum, leads to ischemia and tissue necrosis. For an existing wound, the Key Point! is that all other interventions are futile without first addressing and eliminating the primary cause—pressure. The nursing process dictates that the priority intervention must target the etiology of the problem.
Answer Rationale: Option ④ is correct because it directly addresses the root cause. A turning schedule every 2 hours is the standard of care to prevent prolonged pressure on any single area. Using pressure-redistributing surfaces (e.g., specialized mattresses or overlays) is an essential adjunct to further minimize pressure. This combined intervention is the highest priority to prevent further tissue damage and create an environment conducive to healing.
Distractor Analysis:
Option ① (Hydrocolloid dressing): While appropriate for managing moderate exudate in a stage 3 wound, selecting a dressing is a secondary intervention. It manages the wound environment but does nothing to stop the ongoing pressure that caused the injury and will impede healing.
Option ② (Position on affected area): This is Watch out for confusion! and is contraindicated. Positioning a patient directly on a pressure injury applies pressure to already damaged, fragile tissue, causing further ischemia and necrosis. The goal is to keep pressure off the wound entirely.
Option ③ (Cleanse with hydrogen peroxide): This is an outdated and harmful practice. Hydrogen peroxide is cytotoxic—it damages healthy granulation tissue and fibroblasts, delaying wound healing. Current evidence-based practice recommends cleansing with normal saline or a gentle, non-cytotoxic wound cleanser.
Related Concepts: This scenario integrates gerontological nursing (skin fragility in older adults), post-surgical care (immobility), and wound management. Remember the Braden Scale for predicting pressure injury risk, which includes mobility, activity, and sensory perception as key factors.
Concept Summary
Concept
Key Takeaway
Pressure Injury Etiology
Caused by pressure, shear, friction, and moisture. Pressure is the primary culprit.
Nursing Priority
First, remove the cause (pressure relief). Second, manage the wound (cleansing, dressings).
Stage 3 Pressure Injury
Full-thickness skin loss with damage to subcutaneous tissue. Fat may be visible. Undermining/tunneling may be present.
Turning Schedule
Standard is every 2 hours. Must be documented and consistently implemented.
Wound Cleansing
Use normal saline or approved wound cleanser. Avoid cytotoxic agents (hydrogen peroxide, povidone-iodine, Dakin's solution).
Side-by-Side Comparison!
Intervention
Rationale & Purpose
Priority Level
Pressure Relief (Turning, Surfaces)
Addresses the etiology of the wound. Prevents further damage.
HIGHEST PRIORITY
Appropriate Dressing Selection
Manages the local wound environment (moisture balance, infection control).
Secondary Priority
Nutritional Support (Protein, Calories)
Addresses systemic factors for healing (co-morbidity).
Concurrent Priority
Anatomy, Physiology & Pharmacology Points
Pathophysiology: Sustained pressure > capillary occlusion > tissue ischemia > necrosis. The sacrum is a high-risk area due to its bony prominence and weight-bearing in supine/sitting positions.
Wound Healing Stages: Inflammatory, Proliferative, Maturation. Pressure must be offloaded for the proliferative phase (granulation tissue formation) to occur.
Dressing Pharmacology: Hydrocolloids (e.g., DuoDERM) provide a moist environment and are semi-occlusive. They are not suitable for heavily exudating or infected wounds.
Memory Tips
ABCs of Wound Care: Assess & Address the Cause first! Then Basic care (cleanse), then Choose a Covering (dressing).
Turning Rule: "Q2H" – Every 2 Hours. Think of the clock as your patient's best friend.
Hydrogen Peroxide: Remember "H2O2 hurts healing." It's for disinfecting surfaces, not human tissue.
High-Frequency NCLEX Topics
Pressure injury prevention and management is a Core and High Yield topic. The NCLEX loves to test:
Identifying the correct stage of a pressure injury from a description.
Selecting the priority nursing intervention (always pressure relief first!).
Knowing contraindicated actions (e.g., massaging reddened areas, using harmful cleansers).
Understanding the use of risk assessment tools like the Braden Scale.
Watch Out for Question Variations!
Shift from Intervention to Assessment: "The nurse assesses a stage 3 pressure injury. Which finding should the nurse document?" (Answer: Visible subcutaneous tissue/fat, undermining).
Shift to Patient Education: "Which statement by a family member caring for a bedridden patient indicates understanding of pressure injury prevention?" (Answer: "I will help him change position every two hours.")
Shift to Delegation: "Which task can the RN delegate to an LPN/LVN regarding this patient's pressure injury?" (Answer: Performing the scheduled wound dressing change per protocol. The RN retains responsibility for assessment, care planning, and evaluating the effectiveness of the turning schedule).
Nursing Clinical Practice GuideClinical Scenario: You are the day-shift nurse for Mr. Johnson, an 82-year-old with dementia, recovering from a hip pinning. He is confused, has limited mobility, and a new Stage 3 sacral pressure injury was noted during morning care. The wound has a foul odor and yellow slough.
Nursing Intervention Strategy:
Assessment: Perform a comprehensive wound assessment using the TIME framework (Tissue, Infection/Inflammation, Moisture balance, Edge of wound). Measure dimensions, note exudate, odor, and peri-wound skin. Reassess his Braden Scale score.
Planning & Implementation:
Priority Action: Collaborate with the team to place Mr. Johnson on a low-air-loss or alternating pressure mattress. Document and enforce a strict turning schedule every 2 hours using a clock/timer. Use pillows and positioning devices to keep pressure off the sacrum (e.g., 30-degree lateral tilt).
Wound Care: Cleanse with normal saline. Based on the moderate exudate and possible infection, the provider may order a wound culture and select an antimicrobial dressing (e.g., silver alginate) instead of a plain hydrocolloid.
Systemic Support: Consult dietary for a high-protein, high-calorie diet with vitamin C and zinc supplements to support healing.
Evaluation: Monitor for signs of healing (reduction in size, clean granulation tissue) or deterioration (increased size, purulent exudate, fever). Evaluate adherence to the turning schedule.
Patient Safety and Precautions:
Never use donut-shaped cushions. They increase pressure on the surrounding tissue and impair circulation to the wound area.
Use lift sheets during turns to minimize shear and friction forces.
Keep the skin clean and dry. Use a moisture barrier cream on intact peri-wound skin.
Monitor for signs of systemic infection (Sepsis) from the wound.
Cleanse wound from center outward with sterile saline.
Pat dry surrounding skin.
Apply prescribed dressing.
Secure dressing. Label with date/time/initials.
Document assessment findings and procedure.
Turning Schedule Logistics: Use a turning clock chart in the room. Communicate the schedule clearly during handoff report. Involve nursing assistants and family (if appropriate) in the repositioning plan.
A Word from Your Senior Nurse
"In the real world, preventing a pressure injury is ten times easier than treating one. For this patient, the turning schedule isn't just a task on a checklist—it's his lifeline to healing. Be the nurse who ensures it happens consistently, even on busy shifts. When you see a stage 3 wound, think beyond the dressing. Ask yourself: 'What is still pressing on this wound?' Your critical thinking in removing that pressure is what makes you a true patient advocate and a skilled clinician. This mindset is exactly what the NCLEX is testing."