Final answer:
The nurse should document the findings and continue monitoring the patient's skin over the coccyx. The redness and warmth could be signs of increased blood flow returning after pressure was relieved. Monitoring is essential to prevent the formation of pressure ulcers.
Step-by-step explanation:
The nurse has assessed an area of pale white skin over a patient's coccyx that turns red and feels warm after repositioning. This suggests that the skin could be experiencing the initial stages of a pressure ulcer (bedsore) due to prolonged pressure, which has caused temporary ischemia (restricted blood flow). When the pressure is relieved, the skin turns red due to reactive hyperemia, which is an increased blood flow to the area. Given that the skin integrity is not broken, the correct response would be option b: Document the findings and continue monitoring. It's important for the nurse to continue to monitor the area for any signs of deterioration, which could indicate the formation of a bedsore. Furthermore, implementing preventive measures such as frequent repositioning, using support surfaces, and ensuring good skincare are crucial steps in preventing the development of pressure ulcers.
Watching for increased redness, swelling, and pain after a cut or abrasion has been cleaned and bandaged is essential as these signs can indicate an infection. The risk of infection is particularly high in individuals with compromised immune systems or chronic conditions such as diabetes. An infection can quickly progress to more serious conditions such as cellulitis or, in severe cases, necrotizing fasciitis, which is a rapid, life-threatening infection of the soft tissue.