Sacral Pressure Injury in a Stroke Patient with Incontinence
Mr. K., 68, is on a 28-bed medical ward three weeks after a left middle cerebral artery stroke that left him with left hemiplegia and mild dysphagia. His Braden score is 11 (sensory perception 2, moisture 1, activity 1, mobility 2, nutrition 3, friction/shear 2). Over the sacrum there is a 3 cm × 2 cm area of non-blanchable erythema; the skin is intact. He is incontinent of urine three or four times each night and has loose stools every second day. He eats less than half of each meal and his serum albumin is 2.9 g/dL. His daughter brings oily rice and sweet coffee every evening. He attends physiotherapy for 30 minutes daily. A pressure-redistributing mattress is shared among four patients and is not currently on his bed. The night shift has one staff nurse for 28 patients, and turning happens mainly when relatives ask. The doctor has ordered two-hourly repositioning, skin cleansing after each incontinence episode, and a dietitian referral.
1. Identify the two highest-priority nursing problems for Mr. K. and justify each using the assessment data. State one measurable goal for each problem.
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Highest priority: (1) risk of deterioration of the existing sacral pressure injury. The Braden score of 11, moisture score of 1, immobility, and non-blanchable erythema indicate a category 1 pressure injury already present; moisture and immobility are modifiable, so this is the most urgent nursing problem. Goal: within 48 hours, the sacral area will show no enlargement, blistering, or breakdown, measured daily and documented by size and description. (2) Impaired nutritional intake. Eating less than half of meals with albumin 2.9 g/dL reduces tissue repair and increases pressure-injury risk; albumin below 3.0 g/dL is associated with delayed healing. Goal: within five days, Mr. K. will consume at least 75% of prescribed meals with dietitian-approved protein supplements, recorded on an intake chart. I would not choose 'risk for infection' first because the skin is intact, and I would not choose 'impaired physical mobility' as the top problem because it is already addressed by physiotherapy and is less immediately modifiable than moisture and pressure.
2. Design a repositioning and skin-care plan that one night nurse can realistically carry out for 28 patients, and explain how the family can help without transferring nursing responsibility.
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With one nurse for 28 patients, turning every patient two-hourly is not achievable, so I would risk-stratify. Mr. K. has a Braden score of 11 and should be on the shared pressure-redistributing mattress at night. I would group turns with incontinence checks at 22:00, 00:00, 02:00, 04:00, and 06:00, using a 30-degree lateral tilt with pillows rather than a full turn. A bedside turning clock and a simple chart would record time, position, and skin condition. I would ask the night supervisor for a second aide between 00:00 and 04:00, the highest-risk period, and would prioritise the three or four patients with Braden scores of 12 or less. The daughter can be shown how to help with the 22:00 and 06:00 turns while the nurse inspects the skin and performs cleansing. I would explain that this is assistance, not transfer of responsibility: the nurse remains accountable for skin assessment, documentation, and escalation. I would document who turned the patient, the position used, and any change in the sacral area.
3. The family refuses dietitian advice, saying 'he needs rice for strength.' Explain how you would counsel them using the albumin and intake data, and what you would document.
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I would start with the data rather than blame: 'His albumin is 2.9 g/dL, which is low. Albumin is a protein, and low albumin is linked to poor healing and more fluid leaking into the tissues. He is eating less than half his meals, so rice alone is not giving him enough protein.' I would keep rice in the plan because it is familiar, but negotiate additions: dal, egg, curd, or a prescribed protein supplement at each meal, and small frequent feeds. I would ask the dietitian for a culturally acceptable plan rather than simply repeating the referral. Sweet coffee can stay as one cup if he enjoys it, but I would explain that it adds energy without protein and may reduce appetite for meals. I would document the family's concerns in their words, the teaching given, the foods agreed, the intake chart, and the dietitian referral. At 48 hours I would review intake; if it remains below 50%, I would escalate to the doctor for an oral nutrition supplement.