If non-blanchable redness is observed during repositioning, what action is recommended?

• A. Reposition the patient and document the finding; monitor the area
• B. Ignore if painless
• C. Massage the area vigorously
• D. Apply a cold compress and continue

Answer: (B)

Non-blanchable redness is an early warning sign that tissue under the skin is at risk from pressure. When you observe it during repositioning, the priority is to relieve the pressure on that spot and prevent further injury. Reposition the patient to offload the affected area, use a pressure-relieving surface or positioning aid, and then document what you found and your actions. Reassess the area at each turn to monitor for changes in color, swelling, warmth, or breakdown, and ensure skin care and moisture control to keep the skin healthy.

Ignoring the finding because there is no pain is not appropriate, since tissue damage can be progressing even without pain. Massaging the area vigorously can cause further tissue damage and does not relieve pressure. A cold compress and continuing the same position won’t help and can harm tissue by reducing blood flow and causing further injury. The correct approach focuses on offloading pressure, documenting the finding, and monitoring the area.