Question

During morning care in a skilled nursing facility, the student nurse notices that a patient who is at risk for impaired skin integrity has developed a small open area on his sacrum. To best address this situation, the student would first:

a. position the patient to lie on his side, document it, and inform the head nurse.
b. position the patient on his side and encourage him to massage around the area
c. report to the physician so the the nursing care plan can be revised
d. tell the nursing assistant to change the patient's position every 2 hrs.

Answer 1

The student nurse should first reposition the patient to lie on their side, document the skin integrity issue, and inform the head nurse, which could lead to the revision of the patient's nursing care plan under the direct supervision of a registered nurse.

Step-by-step explanation:

When addressing the situation where a patient at risk for impaired skin integrity has developed a small open area on his sacrum, the first step would be to reposition the patient to lie on their side. This alleviates pressure on the affected area and helps to prevent further damage to the skin. After repositioning, it is critical to document the finding and inform the head nurse immediately so that the necessary changes to the nursing care plan can be made, which may include notifying the physician for further intervention.

Prolonged pressure on bony areas such as the sacrum can reduce blood flow, leading to tissue damage and the development of bedsores, also known as decubitus ulcers. Regularly turning the patient every few hours is a standard practice to prevent bedsores, and careful monitoring is essential for those at risk. Massaging the area is not recommended, as it can cause further harm to already damaged tissue. It is also important that any changes to the patient's care, including the frequency of repositioning, are done under the direct supervision of a registered nurse.