Pressure Injury Risk after a Stroke
Anita, a home health aide, is assigned to a 72-year-old woman, Kamala, who had a stroke 10 days ago and has left-sided weakness. Kamala can speak but cannot move her left arm or leg. She has been lying mostly on her back because her daughter, who provides most care, is afraid that turning will cause pain and 'break a bone'. On day 10 Anita notices a red, warm area over the sacrum that does not blanch when pressed. Kamala has mild fever (37.8°C), a urinary catheter, and is incontinent of stool occasionally. The family has one bed, no air mattress, and a shortage of clean bed linen. The daughter says, 'We were told to rest her completely.' Anita has no nurse on site and must report by phone at the end of the visit.
1. What is Anita's main concern, what stage of pressure injury is this likely to be, and what immediate actions should she take? Explain your reasoning.
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The main concern is a developing pressure injury over the sacrum. The red, warm area that does not blanch is likely a stage 1 pressure injury: the skin is intact but showing pressure damage. Anita should relieve pressure immediately by turning Kamala onto her side with a 30-degree tilt, using pillows, and repositioning every two hours, including at night. She should keep the area clean and dry, clean stool promptly, and avoid massaging the red area because massage can worsen tissue damage. She should check the catheter and urine because fever and a catheter raise the risk of urinary infection. She should inspect the rest of the skin, document the size and colour, and report to the nurse or doctor by phone. Increasing protein and fluids, if allowed, supports healing, but pressure relief is the first priority.
2. The daughter says, 'We were told to rest her completely.' How should Anita respond while still getting the needed care done?
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Anita should agree with the part that is true: 'Yes, she needs rest, and we will not make her sit up or walk.' Then explain the difference: 'Rest does not mean lying in one position. Staying on one spot cuts off blood to the skin and causes a wound.' Demonstrate a gentle turn with a pillow behind the back and show that the bone is supported, not pulled. Time the turn after pain medicine if prescribed, and ask the daughter to place the pillow so she feels involved. Agree on a two-hour schedule and write it down. If the daughter still refuses, Anita should not force her; she should report the refusal and ask the nurse to speak with the family. This respects the family's fear while protecting Kamala from further skin damage.
3. Which findings would make Anita contact the nurse or doctor the same day?
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Same-day contact is needed for fever above 38°C, spreading redness, warmth, or swelling, a new blister or open area, foul-smelling urine, confusion or new drowsiness, inability to pass urine, or severe pain. Also report if Kamala cannot be repositioned because of pain or breathing difficulty, if the daughter refuses all turning, or if there is no clean linen to keep the skin dry. These findings could mean wound infection, urinary infection, sepsis, or a worsening general condition. Anita should record the time, the exact observation, and what she did, and ask for clear instructions. She should not wait for the next routine visit because pressure injuries and infections can progress quickly in an elderly, immobile patient.