A nurse is assessing a 78-year-old patient who has been bedr… | 마이메르시 MyMerci
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문제

A nurse is assessing a 78-year-old patient who has been bedridden for 10 days following hip fracture surgery. The nurse notices a localized area of intact skin that appears purple or maroon colored over the patient's sacral area. Which assessment finding would be most indicative of a deep tissue pressure injury?

A 78-year-old patient has been bedridden for 10 days following hip fracture surgery. The nurse notices a localized area of intact skin that appears purple or maroon colored over the patient's sacral area.
해설
Deep tissue pressure injury presents as intact skin that is purple or maroon colored and may feel boggy or firm, indicating underlying tissue damage from pressure. Other options describe different pressure injury stages or characteristics.
같은 주제 다음 문제A nurse is assessing a 65-year-old patient who has been immobile in a wheelchair for 4 wee…

심화 해설

Clinical Judgment This question evaluates prioritization and clinical judgment. The core is asking for the "highest priority (immediate nursing intervention)." All options are skin issues, but their severity and urgency differ. Advanced age, immobility, and postoperative status are major risk factors for pressure ulcer development. In this context, a Stage 2 pressure ulcer on the heel indicates that tissue damage has already progressed, posing a high risk of further deterioration and serious infection. The heel, in particular, is an area with poor blood supply and concentrated pressure, making healing difficult and requiring immediate and active intervention. In contrast, a Stage 1 pressure ulcer is an early stage with intact skin, and dry skin or a small skin tear are relatively less urgent issues in the current situation. Memory Tip: Prioritization Tip: Think "Progressed Wound in a High-risk Patient." Progressed wound (Stage 2+) + High-risk patient (elderly, immobile) = Top priority. KR vs US While pressure ulcer prevention and management are important in Korea, the US NCLEX and clinical settings heavily emphasize the immediacy of intervention based on the pressure ulcer stage and the importance of documentation. Discovering a Stage 2 or higher pressure ulcer is considered a significant event requiring notification of the healthcare provider (Notify HCP) and immediate initiation of a standardized wound care protocol.

임상 시나리오

Clinical Assessment Guide for Suspected Deep Tissue Pressure Injury

When assessing a bedridden patient with a suspected deep tissue pressure injury (DTPI), focus on differentiating it from other pressure injury stages. The key is recognizing that the epidermis may remain intact while significant necrosis develops in the deep muscle and adipose layers over a bony prominence.

Critical Assessment Cues
  • Color: Persistent, non-blanchable deep red, maroon, or purple discoloration. This differs from the bright red, blanchable erythema of a Stage 1 injury.
  • Skin Integrity: The skin is typically intact, which rules out Stage 2, 3, or 4 injuries.
  • Texture: Palpate the area gently. A boggy or mushy feel indicates tissue liquefaction and edema. A firm or indurated feel suggests hardened, non-viable tissue. These textural changes are a hallmark of DTPI.
  • Temperature: The area may feel warmer or cooler compared to adjacent skin due to altered perfusion and inflammation.
  • Pain: The patient may report pain or tenderness at the site, even before visible skin changes are pronounced.
Nursing Actions and Documentation
  • Document the exact location, size (length, width, depth if applicable), color, temperature, and texture of the area.
  • Use a validated pressure injury risk assessment scale (e.g., Braden Scale) to identify other risk factors.
  • Implement an aggressive offloading and pressure redistribution plan. Position the patient to completely relieve pressure from the sacrum using a 30-degree lateral turn, pillows, wedges, and a high-specification support surface.
  • Protect the site from further friction and shear. Use a lifting device to move the patient; avoid dragging.
  • Monitor the site closely every shift for evolution. A DTPI can rapidly deteriorate, revealing a full-thickness ulcer under a thin layer of eschar or blister.
  • Maintain meticulous skin care, keeping the area clean and dry, and optimize nutrition and hydration to support tissue viability.
Important Consideration

Do not massage or vigorously rub the area, as this can further damage fragile capillaries and worsen the injury. The evolution of a DTPI may include the formation of a thin blister or a dark, necrotic wound bed, which should be managed by a wound care specialist.

핵심 개념

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