Question

wound care consult: client has been spending several hours each day in a wheelchair and has now developed a pressure injury on the coccyx. prior to the accident, the client lived alone at home and was independent with all activities of daily living. pre - existing conditions included morbid obesity and hypertension controlled with a beta blocker. current labs significant for low albumin of 2.9 g/dl (29 g/l). the pressure injury is irregularly shaped, approximately 5.7 inches (14.48 cm) in diameter across the coccyx. there is a bright red skin border of intact skin about 1 inch (2.54 cm) wide, leading into an area of approximately 3.6 inches (9.14 cm) diameter where the skin is completely broken down and subcutaneous fat is clearly visible. the area is damp with oozing serous fluid. no undermining or tunneling is noted; no slough or eschar is seen; no foul odor is noted. plan: negative pressure wound treatment system will be applied with dressing changes bi - weekly by wound care team. the nurse focuses on which 3 priorities for this clients care? 1. preventing hospital acquired delirium. 2. preventing a urinary tract infection (uti). 3. keeping the client off the current pressure injury. 4. monitoring closely for pulmonary emboli. 5. preventing constipation. 6. preventing further pressure injuries from developing. 7. increasing the clients protein intake. 8. monitoring and treating peripheral neuropathy.

Explanation:

1. Option 3: The client has a pressure injury on the coccyx, so keeping them off this area is crucial to prevent further damage and promote healing.
2. Option 6: Since the client is in a wheelchair (at risk for pressure injuries) and already has one, preventing new pressure injuries (via repositioning, pressure - relieving devices) is a priority.
3. Option 7: The client has low albumin (a protein marker), and adequate protein intake is essential for wound healing and preventing further tissue breakdown.

Options 1 (delirium not indicated), 2 (UTI not a primary concern here), 4 (pulmonary emboli risk not highlighted), 5 (constipation not a priority), 8 (peripheral neuropathy not mentioned) are not priorities.

Answer:

1. Keeping the client off the current pressure injury.
2. Preventing further pressure injuries from developing.
3. Increasing the client's protein intake.