After completing a scheduled every-two-hour turn by turning the client to the left side, the nurse notices a reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area?

Question

Quizplus · Accepted Answer

Reactive hyperaemia is the correct term to describe a reddened area that blanches with pressure and then returns to normal color after the pressure is removed. This indicates that the blood flow has returned to the area, which is a normal physiological response to relieve pressure, not a pressure ulcer.

After Completing a Scheduled Every-Two-Hour Turn by Turning the Client