Gown Change, an IV Line, and a Red Spot That Does Not Blance
Mrs. Alvarez, 84, had a left-sided stroke three weeks ago. She has left hemiplegia and an IV running in her left forearm. You are doing a partial bath and gown change before her daughter arrives at 10:00; it is now 9:15. She can sit on the edge of the bed with one-person assist and bears weight well on her right leg. She has been incontinent of urine, and her brief has not been checked since 6:30 a.m. There is a quarter-sized reddened area over her sacrum that does not blanch when you press it; yesterday's note described that area as blanchable. She is alert and answers in short phrases.
1. In what order do you carry out the brief change, bath, and gown change, and how do you manage the gown around the IV and her weak side?
Read the worked answer
Order: check and change the wet brief first, then bathe and dry the skin, then put on the clean gown.
Why that order: urine has been against her sacrum for nearly three hours. Wet skin over a reddened area breaks down faster, so removing the moisture source comes before everything else, and you want to see and dry the skin before it is covered again. Wash with gentle soap and warm (not hot) water, rinse, and pat dry - especially the perineum and the skin folds.
Gown technique:
- Undress the unaffected (right) side first, then ease the gown over the left arm.
- Dress the affected (left) side first, then the right.
- Thread the IV bag and tubing through the sleeve without tugging the catheter; check that the site is intact and the tubing is not kinked or pulled when she moves.
Give her one instruction at a time ('hold the gown here'), and let her do the right arm herself if she can - that is dressing practice, not just a bath.
2. Which of your findings is the priority to report, and what exactly do you say?
Read the worked answer
The sacral redness that no longer blanches is the priority finding.
- It was documented as blanchable yesterday; today it does not blanch. That change means tissue damage is progressing and it needs a nurse's assessment and a care-plan change (turning schedule, support surface, moisture management).
- Report the size (quarter-sized), the exact location (sacrum), that it does not blanch, that she has been lying in urine, and the time you found it.
- Also report the IV site condition and how much she drank at breakfast, but say the skin finding first.
What you do not do: do not massage the reddened area, do not rub lotion, powder, or ointment on it, and do not apply heat. Friction and moisture make it worse. Do not chart 'red area, will monitor' and move on - a non-blanching area is a report-now finding, not an observation for later.
After reporting, reposition her off her back and keep her skin clean and dry; those are within your role.
3. You need to take a blood pressure and you are also washing her arms. What do you do about her left arm, and why?
Read the worked answer
Take the blood pressure on her right arm. The left arm has an IV in it and is the hemiplegic side; using it for a cuff risks dislodging the line, causing pain, and giving a reading that is not reliable. If for some reason the right arm cannot be used, do not improvise - ask the nurse.
For the bath:
- Wash the left arm gently and support it with your hand underneath, since she cannot hold it steady.
- Dry it fully, including under the arm, and check the IV site for redness, swelling, coolness, pain, or leakage. Report any of those rather than adjusting the line yourself.
- Check the left hand for swelling and the fingers for color and warmth, and mention anything you find to the nurse.
- Position the arm on a pillow rather than letting it hang or lie pinned under her body; that protects the shoulder and helps prevent later stiffness.
Reasoning: the weak arm is the one most likely to be injured by careless handling. You are not just cleaning it - you are the person most likely to notice a problem with it first.