Recognizing pressure injury risks on morning rounds

Question

Click to highlight the findings that require follow-up.

0600: Resident is 84 years old, is bedbound after a stroke and needs staff to turn her. The turning record shows the last position change at 0200. She is lying on her left side with a pillow between the knees. Skin over the sacrum is intact, with a reddened area that stays red when pressed with a gloved finger. The incontinence brief is soaked with urine, and the skin underneath is damp. Both heels are lifted off the mattress by a pillow under the lower legs. She ate most of her dinner and drank 480 mL overnight. Lips and oral mucosa are moist. She says she slept well.

Highlighted phrases are the correct selections.

Answer

The turning record shows the last position change at 0200. · Skin over the sacrum is intact, with a reddened area that stays red when pressed with a gloved finger. · The incontinence brief is soaked with urine, and the skin underneath is damp.

Rationale

A resident who relies on staff for turning needs a new position at least every 2 hours, so four hours since the last turn calls for action now. Red skin over the sacrum that keeps its color under light pressure, while the skin is still unbroken, marks a stage 1 pressure injury, and that area must be kept free of pressure. Wet skin breaks down more easily, so the soaked brief is changed and the skin cleaned and dried promptly. Side-lying with padding between the knees, floated heels, good intake and moist mucosa are protective or expected.