# A nurse is caring for a 78-year-old patient who has been bedridden for 10 days following hip fracture surgery. The patient has developed a stage 2 pressure injury on the sacrum. Which nursing intervention should be the priority to prevent further deterioration of the pressure injury?

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## 문제

A nurse is caring for a 78-year-old patient who has been bedridden for 10 days following hip fracture surgery. The patient has developed a stage 2 pressure injury on the sacrum. Which nursing intervention should be the priority to prevent further deterioration of the pressure injury?

## 보기

1. Apply a hydrocolloid dressing and change it every 7 days
2. Massage the area around the pressure injury to improve circulation
3. Keep the wound area dry and expose it to air for healing
4. Reposition the patient every 2 hours and use pressure-redistributing surfaces **✔ 정답**

**정답: 4**

## 해설

The priority is to eliminate pressure through repositioning every 2 hours and pressure-redistributing surfaces, addressing the root cause. Other options are less effective or contraindicated for stage 2 pressure injury.

## 심화 해설

Understanding the Clinical Priority

For a 78-year-old bedridden patient with a stage 2 pressure injury, the immediate nursing priority is to eliminate the root cause of the tissue damage. A stage 2 injury involves partial-thickness skin loss with exposed dermis, and it remains reversible if the causative factors—primarily unrelieved pressure and shear—are removed. The foundational evidence underscores that without addressing the mechanical forces at play, any topical wound treatment will fail to prevent deterioration.

The systematic review by Meng et al. (2026) identifies repositioning and the use of support surfaces as core components of "targeted preventive measures" for long-term bedridden patients. These interventions directly counteract the pathophysiological cascade of pressure injury development: sustained external pressure exceeding capillary closing pressure (typically around 32 mmHg) leads to localized ischemia, tissue hypoxia, and eventual necrosis . Repositioning every 2 hours effectively redistributes this pressure away from bony prominences like the sacrum, allowing for reperfusion of the affected tissues.

Peterson et al. (2025) reinforce this by emphasizing that pressure injuries are a "major source of preventable morbidity" in individuals with impaired mobility, and that management must be built on a foundation of pressure redistribution [1]. The randomized controlled trial by Delui et al. (2026) further supports this principle, demonstrating that specialized surfaces (in their study, sheep-felt mattresses) designed to redistribute pressure can significantly reduce the incidence of new injuries in at-risk hospitalized patients [2]. Applying this evidence, the nurse's first action is to implement a systematic turning schedule and ensure the patient is on an appropriate pressure-redistributing surface to halt the progression of the existing sacral wound.

Analysis of Incorrect Options

**Option 1 (Apply a hydrocolloid dressing and change it every 7 days):** While a hydrocolloid dressing is an appropriate choice for a stage 2 pressure injury to maintain a moist wound environment and protect against contamination, it is a secondary intervention. A dressing alone cannot mitigate the ongoing tissue ischemia caused by unrelieved pressure. Applying a dressing without first implementing a pressure-relief plan addresses the symptom (the wound) but not the cause (pressure), and therefore does not take priority in preventing further deterioration [1,3].

**Option 2 (Massage the area around the pressure injury to improve circulation):** Massaging the tissue surrounding a pressure injury is a contraindicated and harmful practice. The underlying pathophysiology involves damaged capillaries and fragile, ischemic tissue. Manual massage can cause further trauma to the microvasculature, increase inflammation, and extend the zone of tissue destruction, potentially converting a partial-thickness injury into a deeper, full-thickness injury [1].

**Option 3 (Keep the wound area dry and expose it to air for healing):** This approach is outdated and counterproductive. Modern wound care principles dictate that a moist wound environment is essential for cellular migration, granulation tissue formation, and re-epithelialization. Allowing a wound to dry out and form a crust leads to cellular desiccation and significantly delays the healing process. The standard of care for a stage 2 injury involves a moisture-retentive dressing, not air-drying .

References (research sources)

- [1]Preventing pressure injuries in individuals with impaired mobility: Best practices and future directions.Research articlePeterson A, Fraix MP, Agrawal DK. (2025) · DOI: 10.26502/jsr.10020455

- [2]The effectiveness of Iranian sheep-felt mattresses on pressure injuries prevention in moderate to high-risk hospitalized patients: a randomized controlled trial.RCT/clinical trialDelui MA, Kameli F, Noori R, Moradi M, Mohammadzadeh F. (2026) · DOI: 10.1186/s12912-026-04366-9

## 임상 시나리오

Clinical Priority for Sacral Pressure Injury

For a bedridden patient with a stage 2 sacral pressure injury, the immediate priority is to eliminate unrelieved pressure and shear forces. A stage 2 injury is reversible only if the root cause is addressed; topical treatments alone will fail if mechanical loading continues. Repositioning the patient at least every 2 hours and utilizing a pressure-redistributing support surface are the foundational, evidence-based interventions to prevent deterioration to a deeper, full-thickness injury.

**Avoid Harmful Practices:** Do not massage the area around or over the injury, as this can cause further capillary destruction and tissue trauma in already ischemic skin. Also, do not leave the wound bed exposed to air to dry out; a moist wound environment is required for optimal healing.

Key Management Steps

- **Repositioning Schedule:** Turn and reposition the patient every 2 hours, using a 30-degree lateral tilt position to offload the sacrum while avoiding direct pressure on the trochanters.

- **Support Surface:** Place the patient on a high-density foam mattress or an alternating pressure mattress to redistribute pressure away from bony prominences.

- **Wound Care:** Cleanse the stage 2 injury with normal saline, apply a hydrocolloid or foam dressing to maintain a moist healing environment, and change the dressing based on exudate levels and manufacturer guidelines.

- **Skin Assessment:** Conduct a comprehensive skin assessment at least once per shift, documenting the injury's dimensions, exudate, and periwound condition to monitor for signs of deterioration.

## 핵심 개념

- **Stage 2 Pressure Injury** — Partial-thickness skin loss with exposed dermis, presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising.
- **Pressure Redistribution** — The process of shifting body weight away from bony prominences through repositioning or specialized support surfaces to maintain capillary blood flow and prevent tissue ischemia.
- **Capillary Closing Pressure** — The minimal pressure required to collapse capillaries, typically around 32 mmHg; external pressure exceeding this threshold leads to localized tissue hypoxia and necrosis.
- **Shear Force** — A mechanical force that occurs when the skin remains stationary while underlying bony structures move, stretching and tearing blood vessels and deep tissues.
- **Moist Wound Healing** — A principle of wound care maintaining a balanced moist environment with appropriate dressings to facilitate cell migration, autolytic debridement, and faster re-epithelialization.

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