A Red Patch and a Two-Person Care Plan
Mrs. Nakamura, 88, had a stroke and has left-sided weakness. Her care plan says reposition every 2 hours, and transfers require two staff and a gait belt. When you turn her at 10:00 you see a quarter-sized red patch over her sacrum that does not fade when you press it. Her left arm is unsupported and hanging off the mattress edge. She says, 'Leave me be - turning hurts my shoulder.' Your coworker has gone to lunch and the nurse is in a wound-care treatment.
1. You are alone and the turn is due. What do you do, and what do you do about the red patch?
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What this tests: whether you improvise a two-person maneuver under time pressure, and whether you recognize a pressure injury in the making.
Do not attempt the turn alone. The care plan specifies two staff for a reason: she has dense left-sided weakness and cannot assist, and a solo pull on an unsupported arm can dislocate or subluxate the shoulder and injure your own back. A solo attempt is not 'getting it done,' it is creating the next incident.
Do instead:
- Call for help - overhead paging, radio, or phone. Ask the nurse to send anyone available.
- While waiting, do what is safe and within scope: support the left arm on a pillow so it is not hanging (never let the weak arm dangle or be pulled), straighten wrinkled or damp linen you can reach, place a pillow under the calves so the heels are off the mattress, and stay with her so she does not try to move herself.
- Report the red patch to the nurse. Quarter-sized, over the sacrum, non-blanching - that is the earliest sign of a pressure injury and it must be documented and assessed today.
- Do not massage it, do not rub lotion on it, and do not put a donut cushion under her. Massage damages tissue that is already injured.
- Chart the delay and its cause - 'Turn due 10:00; second staff unavailable; nurse notified 10:05; repositioned 10:20' - and chart the skin finding exactly as you saw it.
2. She refuses to be turned, saying it hurts her shoulder. How do you handle the refusal?
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What this tests: honoring autonomy without letting a refusal go unreported - especially when skin breakdown is already starting.
What to do:
- Find out what actually hurts. Shoulder pain on turning is common after a stroke and is often about how the arm was handled, not the turn itself. Ask.
- Explain in her terms, plainly: 'There is a red spot on your tailbone. If you stay on it, the skin will break open, and that is much harder to fix than a toothache. Two minutes off it buys you hours.'
- Remove the barrier: time the turn with her pain medication, have a second person support the weak arm on a pillow throughout, and never lift or pull that arm.
- Offer a middle option that still relieves pressure: a 30-degree tilt with pillows behind her back rather than a full side-lying position, if that is acceptable and consistent with the care plan. She stays on her back but off the spot.
- If she still refuses, do not force her. Turning a competent resident against her will is restraint. Leave her comfortable and safe, put the call light in reach.
- Report the refusal to the nurse the same morning, and chart it in her own words: 'Resident states "turning hurts my shoulder"; declined repositioning at 10:20; offered tilt with pillow support; nurse notified.' A refusal that is documented is a care-planning issue; a refusal that is not documented looks like neglect.
The nurse may change the plan - different positioning schedule, a pressure-relieving mattress, or pain management - and that decision is not yours to make.
3. At 14:00 you and a coworker transfer her to the chair. She says she feels dizzy and her left arm is hanging while you hold the gait belt. What are your next actions and your reasoning?
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What this tests: stopping a transfer in progress and recognizing a possible new neurological event.
Immediate actions:
- Stop the transfer. Do not finish lifting her into the chair and do not walk her 'just the few steps.' Lower her back to the bed or into the chair - whichever she is closest to and can be reached safely - and keep her seated or lying.
- Never pull on the left arm. With stroke-related weakness, the shoulder has no muscle tone to hold the joint; pulling causes subluxation and lasting pain. All support goes through the gait belt at the waist, with the weak arm cradled on a pillow in her lap.
- Check her: blood pressure and pulse per facility protocol, color, sweating, and whether the dizziness passes when she is down.
- Look for new stroke signs: facial droop, slurred speech, new weakness or drifting of the right arm or leg, sudden confusion, trouble seeing. New symptoms are an emergency - call the nurse immediately, note the time symptoms began, because that time determines treatment.
- Do not leave her alone while she is symptomatic, and do not try the transfer again today without the nurse's direction.
Report and chart: what she said, the time, what she was doing, what you did, the vital signs, and whether the dizziness resolved on sitting or lying. Feeling dizzy on standing is often orthostatic - a drop in blood pressure on standing - but after a stroke, a new deficit must be ruled out, and that judgment belongs to the nurse, not the aide. Documenting 'transfer completed, no problems' after this event would be a serious error.