Pressure Injury Prevention in a Client with Limited Mobility
Mrs. Garcia, a 78-year-old female, is admitted with a fractured right hip and is on bed rest. She has a history of type 2 diabetes, peripheral arterial disease, and incontinence. She weighs 50 kg and is 160 cm tall (BMI 19.5). She is alert but weak and requires assistance with all activities of daily living. The LPN notes a 2 cm x 2 cm area of non-blanchable erythema on her sacrum. The care plan includes turning every 2 hours, a pressure-redistribution mattress, and nutritional support.
1. What risk factors place Mrs. Garcia at high risk for pressure injuries? How would you stage the current skin finding?
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Risk factors:
- Immobility: Bed rest and hip fracture limit repositioning.
- Age: Older adults have thinner skin, decreased subcutaneous fat, and reduced circulation.
- Incontinence: Moisture from urine and feces macerates skin and increases friction.
- Malnutrition: BMI 19.5 indicates low body weight; poor nutrition impairs skin healing.
- Diabetes: Neuropathy and poor circulation reduce skin integrity and healing.
- Peripheral arterial disease: Impaired blood flow to extremities increases risk.
- Shear and friction: Moving up in bed can cause shear injury.
Staging: The 2 cm x 2 cm non-blanchable erythema on the sacrum is a Stage 1 pressure injury. It indicates intact skin with non-blanchable redness, a precursor to more severe injury.
Rationale: Identifying risk factors allows targeted prevention. Stage 1 requires immediate intervention to prevent progression.
2. What interventions should the LPN implement to prevent further pressure injury and promote healing? Prioritize your actions.
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Priority interventions:
- Repositioning: Turn and reposition Mrs. Garcia every 2 hours, even at night. Use a lift sheet to minimize friction and shear. Avoid positioning directly on the sacrum; use a 30-degree lateral tilt.
- Skin care: Keep skin clean and dry. Cleanse with pH-balanced cleanser, pat dry, and apply barrier cream to prevent incontinence-associated dermatitis. Do not massage reddened areas.
- Support surfaces: Maintain the pressure-redistribution mattress. Consider additional offloading with pillows or foam wedges.
- Nutrition: Consult dietitian; ensure adequate protein (1.2-1.5 g/kg/day) and calories. Encourage fluids.
- Monitoring: Assess skin daily, especially bony prominences. Document size, location, and stage. Measure the Stage 1 area and monitor for changes.
- Mobility: Collaborate with physical therapy for safe mobility and transfer techniques.
- Education: Teach Mrs. Garcia and family about pressure injury prevention and the importance of reporting discomfort.
Rationale: Repositioning and skin care are cornerstone interventions. Nutrition supports tissue repair. Early detection prevents progression.