Maya, who is admitted to a hospital, is scheduled to have her general checkup and physical assessment. Nurse Timothy observed a reddened area over her left hip. Which should the nurse do first?
A. Massage the reddened area for a few minutes.
B. Notify the physician immediately.
C. Arrange for a pressure-relieving device.
D. Turn the client to the right side for 2 hours.
Correct Answer: D. Turn the client to the right side for 2 hours
Turning the client to the right side relieves the pressure and promotes adequate blood supply to the left hip. Encourage the patient to change position every 15 minutes and change chair-bound positions every hour. During sitting, the pressure over the sacrum may exceed 100 mm Hg. The pressure needed to close capillaries is around 32 mm Hg; any pressure above 32 mm Hg leads to ischemia.
Option A: A reddened area is never massaged, because this may increase the damage to the already reddened, damaged area. Massage only around the affected area. This is to increase tissue perfusion. Massaging the actual reddened area may damage the skin further.
Option B: The health care provider does not need to be notified immediately. However, the health care provider should be informed of this finding the next time he is on the unit. Educate the patient and caregiver about the causes of pressure. This information can assist the patient or caregiver in finding methods to prevent skin breakdown.
Option C: Arranging for a pressure-relieving device is appropriate, but this is done after the client has been turned. Use pillows or foam wedges to keep bony prominences from direct contact with each other. Keep pillows under the heels to raise off bed. These measures reduce shearing forces on the skin.
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