A nurse is assessing a patient with a suspected deep tissue pressure injury on their heel. The skin is intact but shows a deep maroon discoloration. What immediate action should the nurse take?
Offload pressure from the heel using a foam wedge.
Massage the area gently to increase circulation.
Apply ice packs to reduce discoloration.
Apply transparent dressing to the area.
The Correct Answer is A
A. Offload pressure from the heel using a foam wedge: A DTPI signifies deep tissue damage due to intense and/or prolonged pressure and shear. The priority is to eliminate the source of pressure completely (offload the heel) using appropriate devices like heel protectors or foam wedges to prevent progression of the injury to a deep open wound.
B. Massage the area gently to increase circulation: Massaging a discolored area, especially one suspected of having deep tissue injury, can cause further shearing forces and damage to the already compromised underlying capillaries and tissues.
C. Apply ice packs to reduce discoloration: Ice causes vasoconstriction, which would further restrict the already impaired blood flow to the ischemic tissue, worsening the injury.
D. Apply transparent dressing to the area: While a transparent dressing may be used for protection, it does nothing to relieve the underlying pressure causing the injury. Pressure relief is the priority.
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Related Questions
Correct Answer is D
Explanation
A. Apply a warm compress to the area to improve circulation: Applying heat can increase the metabolic demands of the already compromised tissue, potentially worsening the injury.
B. Document the finding and recheck in 24 hours: A Stage 1 pressure injury requires immediate action to relieve pressure to prevent progression. Delaying intervention for 24 hours can allow the injury to worsen.
C. Massage the area gently to promote blood flow:Massaging a reddened, nonblanching area can intensify the underlying capillary and tissue damage, leading to further tissue necrosis and progression to a deeper stage.
D. Reposition the patient to relieve pressure on the heel: The nonblanchable erythema signifies deep tissue ischemia caused by unrelieved pressure. The most appropriate and critical nursing action is to eliminate the pressure immediately by repositioning the patient so the bony prominence is no longer compressed. This is the only way to reverse the ischemia.
Correct Answer is B
Explanation
A. Sanguineous drainage: Sanguineous drainage is fresh, bright red blood.
B. Serosanguineous drainage: Serosanguineous drainage is a mixture of serous fluid (pale, watery) and sanguineous fluid (blood), resulting in a thin, watery, pale pink or light red color. This is a common, normal finding in the inflammatory and proliferative phases of healing.
C. Purulent drainage: Purulent drainage is thick, opaque, and colored (yellow, green, or brown) with a foul odor, indicative of infection.
D. Serous drainage: Serous drainage is clear, thin, and watery, like plasma. The presence of a pink tint indicates blood, classifying it as serosanguineous.
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