# A nurse is caring for a 70-year-old patient with diabetes and a stage 3 pressure injury on the sacrum. Which nursing intervention should be the highest priority?

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## 문제

A nurse is caring for a 70-year-old patient with diabetes and a stage 3 pressure injury on the sacrum. Which nursing intervention should be the highest priority?

An 82-year-old patient has been bedridden for 3 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.

## 보기

1. Apply a hydrocolloid dressing to the wound
2. Implement a turning schedule every 2 hours **✔ 정답**
3. Cleanse the wound with hydrogen peroxide
4. Massage the surrounding skin to improve circulation

**정답: 2**

## 해설

Implementing a turning schedule every 2 hours is the highest priority to relieve pressure and prevent further tissue damage in a stage 3 pressure injury. Other options (dressing application, wound cleansing with hydrogen peroxide, skin massage) are secondary or potentially harmful interventions.

## 심화 해설

Understanding the Priority: Prevention Over Local Wound Care

For a patient with an existing pressure injury, the immediate instinct might be to treat the wound itself. However, the highest priority nursing intervention is to address the underlying cause to prevent further tissue damage. A stage 3 pressure injury indicates full-thickness skin loss with visible subcutaneous tissue, which develops from unrelieved pressure, typically over a bony prominence like the sacrum. The primary mechanism of injury is sustained pressure that exceeds capillary closing pressure, leading to ischemia, tissue anoxia, and ultimately necrosis. If the source of pressure is not removed, the injury will continue to progress deeper, potentially involving muscle and bone, and new injuries will develop at other pressure points.

Why Repositioning is the Highest Priority

Implementing a turning schedule every 2 hours is the cornerstone of pressure injury prevention and management. This intervention directly counteracts the etiological factor: unrelieved pressure. The evidence strongly supports this as the foundational strategy. A quality improvement process specifically targeting sacral hospital-acquired pressure injuries (HAPIs) was prompted by concerns with "current practices in patient turning and repositioning," directly linking inadequate repositioning to injury development [3]. Furthermore, research into pressure injury prevention care bundles in intensive care units emphasizes that consistent application of preventive measures, with repositioning as a central component, is critical for reducing injury incidence . While a study on paraplegic patients suggests that conventional 2-hour turning has limitations and explores adjunct monitoring, it does not negate the fundamental necessity of a scheduled repositioning regimen; rather, it highlights the need for its meticulous implementation . For a bedridden patient, a systematic turning schedule is the single most effective action the nurse can take to offload pressure from the sacrum, restore blood flow, and halt the progression of the existing wound while protecting other areas.

Analysis of Incorrect Options

- Option 1 (Apply a hydrocolloid dressing): This is a local wound care intervention. While appropriate for a stage 3 pressure injury with moderate exudate to maintain a moist wound environment and provide autolytic debridement, it is a secondary measure. A dressing treats the consequence of the pressure, not the cause. Without first relieving the pressure, any topical treatment will be ineffective as the underlying tissue continues to be compromised.

- Option 3 (Cleanse the wound with hydrogen peroxide): This is a harmful and outdated practice. Hydrogen peroxide is a cytotoxic agent that indiscriminately destroys healthy granulation tissue and fibroblasts, which are essential for wound healing. Modern wound care guidelines universally recommend cleansing with normal saline, making this option contraindicated.

- Option 4 (Massage the surrounding skin to improve circulation): This is contraindicated in pressure injury care. Massaging the skin around a bony prominence subjected to pressure can cause further damage to fragile capillaries and deep tissues that may already be ischemic. The shearing force from massage can lead to tissue deformation and worsen the injury, rather than improving circulation.

Integrating Knowledge, Attitude, and Practice

The rationale for prioritizing repositioning is also reflected in studies examining nurses' knowledge and practice. A cross-sectional study on pressure ulcer prevention found that while nurses may possess adequate knowledge, the translation of that knowledge into consistent clinical practice is a critical gap . The highest priority for a nurse is not just knowing what to do but performing the intervention that addresses the most critical threat first. In this scenario, the nurse's practice must focus on the systemic cause—immobility and unrelieved pressure—by implementing a rigorous turning schedule, which forms the bedrock of all subsequent local wound therapies.References (research sources)

- [3]Implementation of a unit-specific quality improvement process for prevention of hospital-acquired pressure injuries.Research articleKern BK. (2025) · DOI: 10.1136/bmjoq-2025-003379

## 임상 시나리오

Pressure Injury Prevention: Repositioning PriorityAddressing the root cause before local wound care
The highest priority for any pressure injury is to eliminate the source of pressure. Sustained pressure exceeding capillary closing pressure (12-32 mmHg) causes ischemia and tissue necrosis. A strict turning schedule every 2 hours is the cornerstone intervention to halt this process and prevent new injuries.

For a Stage 3 pressure injury with visible subcutaneous tissue, local wound care is secondary. Interventions like applying a hydrocolloid dressing are supportive but will fail if the patient remains on the wound. The care plan must integrate pressure redistribution using a repositioning schedule and support surfaces.

CautionNever massage bony prominences or reddened skin; this causes capillary damage and deep tissue trauma. Avoid cytotoxic cleansers like hydrogen peroxide, which destroy granulation tissue and delay healing.

## 핵심 개념

- **Stage 3 Pressure Injury** — Full-thickness skin loss with visible subcutaneous tissue; fat is visible, but bone, tendon, or muscle are not exposed.
- **Capillary Closing Pressure** — The minimal pressure required to collapse a capillary, leading to tissue ischemia; typically 12-32 mmHg, which is exceeded by sustained unrelieved pressure.
- **Ischemia** — A restriction in blood supply to tissues, causing a shortage of oxygen and glucose needed for cellular metabolism, ultimately leading to tissue necrosis.
- **Hydrocolloid Dressing** — An occlusive or semi-occlusive dressing composed of gel-forming polymers; used for light-to-moderate exudate wounds but not the priority over pressure relief.
- **Repositioning Schedule** — A systematic plan to turn and reposition an immobile patient at regular intervals, typically every 2 hours, to relieve pressure over bony prominences.

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