The unlicensed assistive personnel (UAP) reports finding a reddened area on a client's sacrum during a bath. What is the nurse's priority action? A)Direct the UAP to apply a protective foam dressing B)Document results of the Braden Scale in the electronic record C)Notify the health care provider (HCP) D)Perform an assessment on the client's skin

Question

Quizplus · Accepted Answer

A reddened area on the sacrum puts the client at risk for skin breakdown. The nurse should first perform an assessment on the client's skin to see if there are any other reddened areas or skin breakdown present. This should be compared to previous assessments or serve as a baseline assessment of skin integrity. The Braden Scale, a tool for predicting pressure sore risk, would be appropriate to use as part of the assessment. (Option A) After the nurse has performed a skin assessment, it may be appropriate to direct the UAP to apply a protective foam dressing to the area. (Option B) Documentation should occur after the client has been assessed thoroughly and received care. (Option C) After assessing the client, the nurse can decide whether to notify the HCP. Educational objective: When the nurse receives report of a change in client condition from the UAP, the nurse should reassess the client before completing other interventions.

The Unlicensed Assistive Personnel (UAP) Reports Finding a Reddened Area