A nurse caring a bedridden patient with a pressure ulcer, 2 hourly position changes and massaging & rubbing the back but pressure sore does not heal. What is the expected problem?

1. A

   Do not apply cream

2. B

   Inadequate amount of carbohydrate

3. C

   Inadequate amount of protein

4. D

   massaging and rubbing the back

Appeared in: NORCET 2 -2021 (Shift-2)

Explanation

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• The question describes a nurse performing an incorrect and harmful action: massaging and rubbing the back of a patient with a pressure ulcer.
• Massaging an area with a pressure ulcer or at risk for one is contraindicated because it can cause friction and shear forces, leading to deep tissue trauma and damage to fragile capillaries.
• This action directly impedes the healing process and can worsen the existing wound, making it the most direct and identifiable problem in the given scenario.
• Evidence-based guidelines explicitly state to avoid massaging reddened bony prominences.

Why Other Options Were Wrong

• Option A: While appropriate topical treatments are part of comprehensive wound care, the absence of a specific cream is less likely to be the primary reason for non-healing compared to an actively harmful intervention like massaging.
• Option B: Carbohydrates are essential for providing energy to spare protein for tissue repair. While inadequate intake can hinder healing, it is considered secondary to the importance of protein and is less impactful than the direct tissue damage from massaging.
• Option C: Inadequate protein is a major cause of impaired wound healing. However, the question stem provides a definite, incorrect action (massaging) that is actively being performed. In a test question, an explicit, harmful action often takes precedence over a potential, unconfirmed deficiency.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Pressure Ulcer Management and Contraindicated Interventions to guide bedside assessment, documentation, and the next nursing action.
• A core principle of nursing is 'first, do no harm.' Identifying and ceasing contraindicated practices like massaging pressure-prone areas is a critical patient safety responsibility.
• Nurses must stay updated with evidence-based practice guidelines for wound care, which evolve over time. What may have been thought to be helpful in the past (like massage to 'improve circulation') is now known to be harmful.
• What if the nurse was not massaging the area, but the ulcer was still not healing? The next priority would be a comprehensive nutritional assessment, focusing on protein and calorie intake, as well as assessing for other factors like infection, unrelieved pressure from another source, or worsening of an underlying condition.

How to Approach the Question

• First, carefully read the clinical scenario and identify all the actions being performed by the nurse (2-hourly turning, massaging/rubbing).
• Evaluate each action against your knowledge of standard, evidence-based nursing care for pressure ulcers.
• Recognize that 'massaging and rubbing' a pressure-prone area is a contraindicated action that causes harm.
• Review the options to see if this incorrect action is listed. Option D, 'Massaging,' directly points to this error in practice.
• Consider the other options. While nutrition (protein, carbs) is vital for healing, the question presents an active, harmful intervention, which is a more immediate and definite problem.
• Conclude that the massaging is the most direct problem described in the stem that is preventing the ulcer from healing.

Concept Tested & Keywords

• Concept Tested: Pressure Ulcer Management and Contraindicated Interventions
• Stem keywords: bedridden patient, pressure ulcer, 2 hourly position changes, massaging, rubbing, does not heal
• Lead-in keywords: expected problem

Question ID

Ql6A90oWZVgHjT6jSPeDz9

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 p. 111-113