Client: 82-year-old female, history of a recent stroke with residual left-sided paralysis. Admission Status: Admitted from home with a stage 3 pressure injury on the sacrum. 0800 Assessment: Wound measures 4 cm x 3 cm x 1 cm deep. The wound bed is 70% red (granulation tissue) and 30% yellow (slough). There is a moderate amount of foul-smelling, yellowish-green drainage. History: Urinary incontinence, poor nutritional intake, and limited mobility.
The nurse recognizes that the client's risk for further skin breakdown is primarily increased by:
- The foul odor of the current wound drainage.
- The presence of slough in the wound bed.
- The client's urinary incontinence and immobility. (correct answer)
- The size of the current pressure injury.
Explanation: Urinary incontinence and immobility are the two primary modifiable risk factors driving further skin breakdown in this client. Incontinence exposes periwound and intact skin to prolonged moisture and the chemical irritants in urine, causing maceration and increasing susceptibility to breakdown. Immobility from the stroke and left-sided paralysis means pressure on bony prominences is constant and unrelieved, ischemia develops in compressed tissue, and repositioning cannot occur without assistance. Together, these factors represent the moisture-pressure combination that drives pressure injury development and progression. Foul odor (A) is a sign of infection in the existing wound, not a risk factor for new breakdown elsewhere. Slough (B) indicates devitalized tissue in the wound bed but does not directly increase the risk of new breakdown. Current wound size (D) does not predict risk for additional sites.