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 promote healing and prevent further tissue damage?
1Apply a hydrocolloid dressing and change it every 3 days
2Massage the surrounding skin to improve circulation
3Implement a turning schedule every 2 hours with pressure redistribution surfaces✓ 정답
4Clean the wound with hydrogen peroxide twice daily
해설
The highest priority is implementing a turning schedule every 2 hours with pressure redistribution surfaces, as pressure relief is fundamental to prevent further tissue damage and promote healing in stage 3 pressure injuries. Other interventions like dressings or cleaning are secondary without addressing the root cause of pressure.
Core Nursing ExplanationKey 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 to remove or redistribute the pressure.
Answer Rationale: Key Point! Option ③ is correct because it directly addresses the etiology of the problem. A turning schedule every 2 hours is the standard of care for immobile patients to prevent prolonged pressure on any one area. Using pressure redistribution surfaces (e.g., specialized mattresses, overlays) is an adjunctive measure to further minimize pressure. Without this foundational step, all other wound care interventions will be ineffective, as the wound will continue to deteriorate from ongoing ischemia.
Distractor Analysis:
Watch out for confusion! Option ①: Applying a hydrocolloid dressing is an appropriate secondary intervention for a Stage 3 wound to maintain a moist wound environment. However, it is not the priority. Changing it every 3 days is a typical schedule, but the priority is to first ensure the pressure is off the wound.
Option ②: Massaging the surrounding skin is contraindicated. Massaging over bony prominences or near a pressure injury can cause shear and friction, damaging delicate capillaries and worsening tissue ischemia. This is a critical nursing safety point.
Option ④: Cleaning the wound with hydrogen peroxide is an outdated and harmful practice. Hydrogen peroxide is cytotoxic—it damages healthy granulation tissue and fibroblasts, impairing wound healing. Current evidence-based practice recommends cleansing with normal saline or a gentle, non-cytotoxic wound cleanser.
Related Concepts: Pressure injury staging (NPUAP classification) guides treatment. Stage 3 involves full-thickness skin loss with damage to subcutaneous tissue, but not extending to muscle or bone. Management follows a hierarchy: 1) Pressure Offloading, 2) Moist Wound Healing, 3) Management of Bacterial Load/Infection, 4) Nutritional Support.
Concept Summary
Concept
Key Takeaway
Pressure Injury Etiology
Caused by unrelieved pressure leading to ischemia and tissue necrosis.
Priority Intervention
Pressure redistribution (turning, repositioning, support surfaces) is ALWAYS the top priority.
Contraindicated Actions
Do not massage bony prominences. Do not use cytotoxic agents (hydrogen peroxide, povidone-iodine) for routine wound cleansing.
Wound Bed Preparation
Follow the TIME principle: Tissue management, Infection/Inflammation control, Moisture balance, Edge advancement.
Side-by-Side Comparison!
Intervention
Rationale & Priority
Common Mistake
Turning Schedule & Pressure Redistribution
HIGHEST PRIORITY. Addresses the root cause (pressure). Prevents further damage.
Thinking a dressing or medication is more urgent.
Appropriate Wound Dressing
SECONDARY PRIORITY. Manages moisture and protects the wound bed after pressure is relieved.
Applying advanced dressings without first ensuring offloading.
Nutritional Support (Protein, Calories, Vitamins)
ESSENTIAL SUPPORT. Provides building blocks for tissue repair. A concurrent priority.
Overlooking the patient's nutritional status as a key factor in healing.
Anatomy, Physiology & Pharmacology Points
Pathophysiology: Sustained pressure > capillary closing pressure (approx. 32 mmHg) > ischemia > tissue hypoxia > cell death > necrosis. The sacrum is a high-risk bony prominence.
Dressing Types: Hydrocolloids (e.g., DuoDERM) are occlusive, maintain moisture, and are used for shallow to moderately exudative wounds. For deeper Stage 3 wounds, alginate or foam dressings may be better for absorption.
Cleansing Agents: Normal saline (0.9% Sodium Chloride) is the isotonic, non-cytotoxic standard. Avoid antiseptics like hydrogen peroxide, which work by oxidizing and destroying cells—both bacterial and human.
Memory Tips
Priority Acronym: OFF the Pressure FIRST! (Offloading, Frequency of turns, Support Surfaces).
Massage Mnemonic: "Don't RUB it in!" – Rubbing/massaging around pressure injuries is Bad.
High-Frequency NCLEX Topics
Pressure injury prevention and management is a Core NCLEX topic. The exam consistently tests:
1. Identifying the highest priority intervention (always pressure relief).
2. Recognizing contraindicated actions (massage, donut devices, harsh cleansers).
3. Matching pressure injury stages with correct descriptions.
4. Selecting appropriate support surfaces (e.g., static air overlay for low risk vs. low-air-loss bed for high risk).
Watch Out for Question Variations!
Shift from "Intervention" to "Assessment": "The nurse assesses a red, intact area over a patient's heel. What is the priority action?" (Answer: Implement a turning schedule to prevent Stage 1 from progressing).
Shift to "Patient Education": "Which statement by a family caregiver indicates understanding of pressure injury care?" (Correct: "I will help him change position every 2 hours." Incorrect: "I will rub the red area with lotion.").
Integrated with Nutrition: "A patient with a Stage 3 pressure injury has a serum albumin level of 2.0 g/dL. Which collaborative intervention is essential?" (Answer: Consult dietitian for high-protein nutritional support).
Nursing Clinical Practice GuideClinical Scenario: You are assigned to Mr. Johnson, an 82-year-old male with dementia and limited mobility following a stroke. He has a Stage 3 pressure injury on his sacrum, approximately 4cm in diameter, with yellow slough in the wound bed and minimal serous drainage.
Nursing Intervention Strategy:
Assessment (First & Ongoing): Complete a full skin assessment using the Braden Scale for Predicting Pressure Sore Risk. Measure and document the wound (length, width, depth, tunneling), characteristics (color of wound bed, type of tissue, exudate, odor), and periwound skin. Assess pain related to the wound.
Planning & Implementation (Priority First):
Key Point!Immediately establish and document a turning and repositioning schedule. Use a clock as a reminder: "Turn at 10, 12, 2, 4..." Position with pillows to keep pressure off the sacrum. Use a pressure-redistributing mattress.
Wound Care: Cleanse gently with warm normal saline and gauze. Debride yellow slough as per order (may involve autolytic debridement with a dressing or enzymatic debridement with ointment). Apply a foam dressing to manage minimal exudate and cushion the area.
Collaborative Care: Consult a wound care nurse specialist. Collaborate with the dietitian to ensure adequate protein (1.2-1.5 g/kg/day) and calorie intake, plus vitamins C and A, and zinc.
Evaluation: Reassess the wound weekly for signs of healing (reduction in size, pink granulation tissue, decrease in exudate) or deterioration (increased size, necrotic tissue, new odor, signs of infection). Evaluate adherence to the turning schedule.
Patient Safety and Precautions:
NEVER use donut-shaped cushions. They increase pressure on surrounding tissues and impair blood flow to the area at risk.
Avoid positioning the patient directly on the injury. Use the 30-degree lateral tilt position.
Manage moisture from incontinence meticulously with barrier creams and moisture-wicking pads to prevent periwound skin breakdown (maceration).
Apply a thin layer only to the necrotic tissue (slough/eschar), avoiding healthy skin.
Cover with a secondary dressing as ordered. Frequency is typically once daily.
A Word from Your Senior Nurse
Remember, a pressure injury is often a sign of systemic nursing care needs. That turning schedule isn't just a task on a checklist—it's your commitment to being your patient's advocate for movement and safety. In the real world, you'll face staffing challenges and time constraints, but protecting the skin is a fundamental measure of the quality of care we provide. When you see that wound start to granulate and close because of consistent, diligent offloading, you'll feel the profound impact of your nursing actions. Study these principles not just for the test, but for the real patients who will depend on your knowledge to heal.
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.
Stage 3 Pressure Injury — Full-thickness skin loss with visible subcutaneous fat. Granulation tissue and epibole (rolled wound edges) are often present. Slough or eschar may be visible. Depth varies by anatomical location.
Pressure Redistribution — The therapeutic use of specialized support surfaces (mattresses, overlays, cushions) and repositioning to reduce the magnitude and duration of pressure on vulnerable areas of the body.
Shear Force — A mechanical force parallel to the skin surface that occurs when tissue layers slide over each other, stretching and tearing blood vessels and contributing to pressure injury development.
Hydrocolloid Dressing — An occlusive or semi-occlusive dressing containing gel-forming agents (e.g., gelatin, pectin). It interacts with wound exudate to form a gel, maintaining a moist wound environment and facilitating autolytic debridement.