The patient's sacrum has nonblanching redness on Monday. On Wednesday the nurse determines that the pressure ulcer on the patient's sacrum is stage II despite skin care, including an air-filled mattress overlay

Question

Which is the best nursing intervention to implement? a. Document the extreme progression of the patient's pressure ulcer.
b. Collaborate with the healthcare provider for physical therapy.
c. Reassess the patient's need for a different support surface or bed.
d. Increase the frequency of bathing and li-nen changes as needed.

Answer 1

C
The patient's pressure ulcer is deteriorating. This means that the current skin care plan is unsuc-cessful and needs reevaluation; thus the nurse should assess the patient for a different support surface. He or she should document the patient's skin assessment, but the best response to the patient's deterioration is to reassess the skin care plan and amend it. Nursing collaboration for physical therapy is a reasonable response and potentially benefits the patient on a support surface, especially if the patient is on bed rest; however, the nurse needs to first assess the patient to de-termine whether physical therapy is indicated for the patient. He or she provides bathing for a patient with a pressure ulcer on a routine and as-needed basis but avoids planning frequent baths and linen changes as therapy because excessive bathing strips the skin of essential moisture and surface oils.