After completing a scheduled every-2-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

The reddened area blanching with thumb pressure indicates reactive hyperemia, which is a temporary redness that disappears within a short period of time. This does not meet the criteria for a pressure ulcer staging. It is important for the nurse to document this to alert other healthcare professionals to the area of concern and monitor it for further changes.

After Completing a Scheduled Every-2-Hour Turn by Turning the Client