Nursing Clinical Practice Guide
Clinical Scenario
You are assigned to Mr. Johnson, a 72-year-old who is 3 days post-op from a right hip fracture open reduction internal fixation (ORIF). He has an order for bed rest with bathroom privileges only (BRP). He rates his pain as 6/10 and is reluctant to move. During your morning assessment, you note slight redness on his right heel.
Nursing Intervention Strategy
1. Assessment: Perform a comprehensive skin assessment using the Braden Scale. Document the location, size, color (blanchable vs. non-blanchable), temperature, and integrity of any reddened areas. Assess pain level, mobility, nutritional intake, and continence status.
2. Planning & Implementation:
• Repositioning: Establish and document a turning schedule every 2 hours. Use a clock or timer as a reminder. Use a lift sheet to minimize shear and friction when repositioning.
• Pressure Redistribution: Ensure he has a pressure-redistributing mattress (e.g., foam, alternating air). Place a pillow under his calves to keep his heels off the bed (suspension). Use pillows for positioning to keep bony prominences from direct contact.
• Skin Care: Keep skin clean and dry. Use a pH-balanced cleanser and apply a moisture-barrier cream if needed. Do not massage reddened areas, as this can cause further tissue damage.
• Pain Management: Administer prescribed analgesics 30 minutes before planned repositioning to increase his comfort and willingness to move.
• Nutrition/Hydration: Encourage fluid intake and a diet high in protein and vitamin C to support tissue repair. Collaborate with the dietitian if intake is poor.
3. Patient & Family Education: Explain why frequent turning is necessary ("to keep the blood flowing to your skin"). Teach family members proper techniques if they will be assisting. Encourage small, frequent position changes even while in a chair.
Patient Safety and Precautions
• Never use donut-shaped cushions, as they increase pressure on surrounding tissues.
• Avoid vigorous rubbing during bathing or drying.
• Report any areas of non-blanchable erythema (Stage I), blistering, or open skin immediately.
Nursing Procedure & Medication Flow
Procedure: Repositioning an Immobile Client
1. Explain the procedure to the client.
2. Enlist help if needed.
3. Lower the head of the bed to a flat or low position to reduce shear.
4. Place a lift/turn sheet under the client.
5. Using the sheet, gently and smoothly turn the client to a 30-degree lateral tilt (avoid 90-degree side-lying directly on the trochanter).
6. Support the position with pillows behind the back, between the knees, and under the arms.
7. Ensure heels are suspended.
8. Document the new position and the condition of the skin.
A Word from Your Senior Nurse
"Pressure ulcers are often called 'never events' because they are largely preventable with diligent nursing care. That immobile post-op patient isn't just a diagnosis in bed—they are relying on YOU to be their muscles and their advocate. Your consistent, thoughtful turning and skin checks are what stand between them and a painful, potentially life-threatening wound. On the NCLEX, they test this because in real life, it's fundamental. Remember: See the person, not just the task. Your care makes all the difference."