The Non-Blanching Patch on Day Four
A 68-year-old man is on his fourth day in a district hospital after a left-sided stroke that has left him with right hemiplegia and difficulty in swallowing. He is alert, speaks in short phrases, and is incontinent of urine; no catheter is in place. He cannot turn himself in bed. On the morning round you find a 4 cm patch over the sacrum that is red and does not blanch when you press it with a gloved finger; the skin is intact and unbroken. His daughter has been spooning water and thin rice water into his mouth and says he "coughs a little" after drinking. One nursing aide is on night duty for 18 patients and has been turning him only when she changes a wet sheet. His haemoglobin is 9.4 g/dL and he has been eating about one-third of each meal. The ward has no air mattress and no pressure-relieving cushions.
1. Classify the sacral lesion and set out, in priority order, what you would do about it in the next 24 hours. Justify each step.
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Classification: this is a Stage 1 (Category 1) pressure injury - intact skin with non-blanchable erythema. The redness persists because the small vessels under pressure are already damaged and no longer refill. It is reversible now, but it will ulcerate within days if nothing changes. This is not a 'rash' and must never be rubbed or massaged.
Priority order and reasons:
- Take the pressure off the sacrum now. Position him in a 30-degree lateral tilt with pillows, keeping him off his back. A 90-degree side-lying position shifts pressure onto the trochanter, so it merely moves the problem.
- Control moisture. Urine is the second big cause here. Change wet linen immediately, wash with lukewarm water and a pH-neutral cleanser, pat dry (never rub), and apply a barrier cream. A wet sheet under a paralysed man acts like a chemical irritant on already ischaemic skin.
- Check the whole body - heels, occiput, ears, trochanters, and under any tubing - because if one site has failed, others are at risk.
- Address nutrition and anaemia. One-third intake plus Hb 9.4 g/dL means poor healing; request a dietitian review and medical assessment of the anaemia.
- Get a pressure-relieving surface - a foam overlay at minimum - and escalate to the nurse-in-charge in writing.
- Document and hand over: site, size, stage, colour, date, and the care plan, so the next shift does not repeat the massage and heat-lamp mistakes.
Re-check every shift; if it blisters or breaks, it has become Stage 2 and needs a dressing protocol.
2. The aide says she cannot turn 18 patients two-hourly at night. Design a turning plan that will realistically be followed, and explain how you would document and monitor it.
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The textbook answer - two-hourly turns for everyone - is correct but will fail if it depends on one aide and is never checked. The judgement call is to make the plan feasible so that it is actually done.
The plan:
- Risk-based schedule, not uniform. He is the highest-risk patient on the ward (immobile, incontinent, poor intake, existing Stage 1 lesion), so he gets the tightest schedule: tilt every 2 hours, alternating left 30 degrees, back-up briefly only for procedures, right 30 degrees. Lower-risk mobile patients can be turned four-hourly with active encouragement to move.
- Build turns into work she already does. She already changes wet sheets; link every pad change to a turn, and set a phone alarm for two-hourly checks.
- Recruit the family. Teach the daughter the 30-degree pillow tilt and how to keep the sheet dry - supervised family involvement is legitimate and reduces the load.
- Group the work. Two patients in adjacent beds can be turned together, halving the number of trips.
Documentation: a turning chart at the bed head with time, position, and skin condition at each turn; the aide initials it. The nurse-in-charge reviews it each morning. If the skin over the sacrum worsens despite turns, that is the signal to escalate for a better mattress, not to blame the aide. A plan nobody records is a plan nobody follows.
3. Explain the risk behind the daughter's feeding practice, and state exactly what you would instruct and record.
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The risk: coughing after thin fluids is a warning sign of dysphagia and aspiration. Thin liquids are the hardest consistency to control - they flow fast to the back of the throat before the swallow reflex can close the airway. Stroke patients commonly have silent aspiration, meaning material enters the airway with no cough at all, so the absence of coughing later does not mean safety. The consequence is aspiration pneumonia, which is a leading cause of death in the first weeks after stroke, and it would be wrongly blamed on 'old age'.
What I would do:
- Stop oral fluids by spoon until a swallowing screen is done by the doctor or a trained nurse. Keep him nil by mouth if the screen is failed.
- Position: sit him fully upright, at least 60–90 degrees, for every feed and for 30 minutes afterwards. Never feed him lying flat or half-reclined.
- Consistency: if oral feeding is cleared, use the safest consistency advised (often thickened fluids and soft, moist solids). Thin rice water is exactly the wrong texture. Feed small amounts, one teaspoon at a time, checking that the mouth is empty before the next spoon.
- Oral care after every feed reduces the bacterial load that causes pneumonia.
- Watch for: fever, fast breathing, rattling breath, reduced oxygen saturation, or new drowsiness - report immediately.
Record: time and type of feed, amount taken, any coughing or choking, the position used, and the instruction given to the family in their own language, signed and dated.