# 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?

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## 문제

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.

## 보기

1. Apply a hydrocolloid dressing and change it every 3 days
2. Position the patient on the affected area for short periods to promote circulation
3. Cleanse the wound with hydrogen peroxide twice daily
4. Implement a turning schedule every 2 hours and use pressure-redistributing surfaces **✔ 정답**

**정답: 4**

## 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.

## 심화 해설

Understanding the Clinical Scenario

An 82-year-old patient immobilized after hip surgery presents with a stage 3 pressure injury on the sacrum. The wound extends into the subcutaneous tissue, creating a significant risk for further deterioration into deeper structures. In this context, the immediate priority is not local wound care but halting the causative mechanism: prolonged, unrelieved pressure that compromises capillary blood flow.

Why Pressure Relief is the Highest Priority

Pressure injuries develop when external pressure exceeds capillary closing pressure (typically around 32 mmHg), leading to tissue ischemia, cellular death, and eventual necrosis. A stage 3 injury indicates full-thickness skin loss with damage to the subcutaneous layer, meaning the ischemic threshold has already been breached for an extended period. Any continued pressure on the sacrum will extend the zone of injury deeper and wider. The foundational principle of pressure injury management is to first remove the source of the insult. A systematic review on prevention in long-term bedridden patients identified repositioning and support surfaces as core, interconnected elements of effective care [2]. Without eliminating the causative pressure, any topical treatment applied to the wound will be undermined by ongoing tissue ischemia.

Analysis of the Correct Intervention (Option 4)

Implementing a turning schedule every 2 hours combined with pressure-redistributing surfaces directly addresses the pathophysiology. The 2-hour turning interval is a widely established clinical benchmark designed to restore blood flow before irreversible tissue damage occurs. However, contemporary research highlights that a fixed 2-hour schedule has limitations, and monitoring individual tissue tolerance using skin interface pressure and temperature can further optimize prevention [1]. A quality improvement initiative in an intensive care unit demonstrated that a structured process focused specifically on turning and repositioning was essential to reduce sacral hospital-acquired pressure injuries when a sudden increase in incidence was noted [3]. For this patient, a high-density foam or alternating pressure mattress works synergistically with manual repositioning by reducing the peak pressure over bony prominences below the critical ischemic threshold.

Why the Other Options are Incorrect

Option 1: Apply a hydrocolloid dressing and change it every 3 days.

A hydrocolloid dressing is an occlusive dressing that maintains a moist wound environment and can be appropriate for stage 2 or shallow stage 3 injuries with low exudate. However, this wound has moderate exudate and visible subcutaneous tissue. A hydrocolloid may not manage the exudate volume adequately, risking maceration of the periwound skin. More critically, this option addresses the wound after the damage has occurred, without preventing the ongoing ischemic insult from unrelieved pressure. Wound care is secondary to pressure redistribution. Research on factors associated with healing outcomes in pressure ulcer patients emphasizes that wound management must be paired with effective offloading to achieve closure .

Option 2: Position the patient on the affected area for short periods to promote circulation.

This action is contraindicated. Placing any amount of pressure directly on an existing stage 3 pressure injury will further compress already damaged capillaries, extending the depth and breadth of tissue necrosis. The sacrum must be completely offloaded. Positioning should avoid any direct contact with the wound bed to allow for reperfusion and granulation tissue formation.

Option 3: Cleanse the wound with hydrogen peroxide twice daily.

Hydrogen peroxide is a cytotoxic agent. While it has effervescent mechanical debridement properties, it indiscriminately destroys healthy fibroblasts and granulation tissue along with bacteria. Modern wound care standards recommend cleansing with normal saline or a non-cytotoxic wound cleanser. Using hydrogen peroxide would delay healing by damaging the cellular components necessary for wound repair. This intervention is both harmful and fails to address the primary etiology of unrelieved pressure.

Integrating Evidence into Practice

The core of pressure injury prevention and treatment is a multidimensional pathway that begins with risk assessment and immediate pressure redistribution [2]. For this patient, the 2-hour turning schedule must be rigorously implemented and documented. The choice of a pressure-redistributing surface should be based on the patient's mobility level, body habitus, and the characteristics of the support surface itself. The presence of a stage 3 injury with moderate exudate signals that the patient is in a state of prolonged, severe immobility, making high-specification reactive or active support surfaces necessary. While local wound care, including appropriate dressing selection and gentle cleansing, is important for healing, these measures will fail if the sacrum is not continuously and effectively offloaded. The retrospective analysis of healing outcomes confirms that comprehensive management, which inherently includes pressure mitigation, is associated with better long-term healing trajectories .References (research sources)

- [1]Effectiveness of skin interface pressure and temperature monitoring for pressure injury prevention in paraplegic patients: a comparative study.Research articleMiao A, Lin C, Ni Y, Yin S, Lv C, Huang H, Jiang X, Zhou H. (2025) · DOI: 10.3389/fpubh.2025.1521948

- [2]Prevention and Care of Pressure Ulcers in Long-Term Bedridden Adult and Older Adult Patients in the Community: A Systematic Review.Meta-analysis/systematic reviewMeng L, Banharak S, Sommana C, Ransinyo K, Cheumnok W, Tian J. (2026) · DOI: 10.2147/tcrm.s592581

- [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

Clinical Practice Guide

For an immobile patient with a stage 3 sacral pressure injury, the primary intervention is strict pressure avoidance. Implement a documented turning schedule every 2 hours, alternating between supine, left lateral, and right lateral positions. Use a 30-degree tilted lateral position rather than a 90-degree side-lying position to reduce trochanteric pressure. Offload the sacrum completely when supine by using pillows or wedges.

Integrate a high-specification reactive foam or alternating pressure air mattress as a pressure-redistributing surface. Assess the wound for signs of infection, tunneling, or undermining during each dressing change. Select a dressing that maintains a moist wound environment while managing moderate exudate, such as a foam or alginate dressing, avoiding cytotoxic agents like hydrogen peroxide.

Optimize systemic factors to support healing: ensure adequate protein and calorie intake, monitor serum albumin and prealbumin, and manage pain to facilitate repositioning. Document wound dimensions, exudate characteristics, and periwound skin condition weekly to track progress.

## 핵심 개념

- **Capillary closing pressure** — The minimum external pressure (typically around 32 mmHg) required to collapse capillaries, leading to tissue ischemia and pressure injury development.
- **Stage 3 pressure injury** — Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue; muscle and bone are not exposed.
- **Pressure-redistributing surfaces** — Support surfaces such as specialized mattresses or overlays designed to reduce interface pressure over bony prominences.
- **Tissue ischemia** — Insufficient blood flow and oxygen delivery to tissues, often caused by unrelieved pressure, leading to cellular death and necrosis.

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