A patient with a stage 3 pressure ulcer on the heel has developed signs of infection. Which of the following actions should the nurse prioritize?

A. Measure undermining and tunneling separately and record them individually.Undermining and tunneling are separate, distinct characteristics of a wound that indicate the extent of tissue destruction under the wound edges. They must be measured individually at their deepest/widest point (using the clock face method to note their location) and recorded separately from the wound's overall length, width, and depth. This provides the most accurate assessment of the wound's progression or regression.

B. Include undermining and tunneling measurements within the wound's depth.Undermining and tunneling are measured horizontally under the wound edges (undermining) or in a specific direction away from the wound bed (tunneling). They are separate from the maximum vertical depth of the visible wound bed itself. Combining them would lead to an inaccurate measurement of the wound's true depth and extent.

C. Use a ruler to measure only the wound's length and width.While length and width are essential, failing to measure and record the depth, undermining, and tunneling in a complex wound like a pressure injury would result in an incomplete and insufficient assessment of tissue damage.

D. Estimate the measurements visually. Accurate wound management requires precise, objective measurements to monitor healing progress. Visual estimation is subjective and prone to significant error, which can compromise treatment decisions.

A. A patient with adequate hydration and skin care regimen.Adequate hydration and a good skin care regimen are preventive measures that significantly decrease the risk of developing a pressure injury.

B. An immobile patient with poor nutritional status.Immobility (prolonged, unrelieved pressure and shear) is the primary mechanical cause of pressure injuries. Poor nutritional status (specifically, low protein and poor hydration) compromises the integrity of the skin and the body's ability to repair tissue, drastically multiplying the overall risk.

C. A mobile patient with a history of diabetes.While diabetes is a risk factor due to poor circulation and neuropathy, a mobile patient can independently relieve pressure, which is the most critical factor in prevention. Therefore, they are at a lower risk than an immobile patient.

D. A patient who regularly changes position every hour.Regular repositioning (typically every two hours in bed, or more frequently in a chair) is the single most effective intervention for preventing pressure injuries. This patient is actively mitigating their risk.