An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse.
What statement by the client may indicate a barrier to proper foot care?

While nutritional status is crucial for wound healing, and labs such as albumin (normal range 3.5-5.0 g/dL) and prealbumin (normal range 15-36 mg/dL) are important indicators, assessing the underlying cause of non-healing is a priority. Drawing labs is a subsequent step after a thorough assessment has been completed to rule out circulatory issues as the primary cause.

Choice B rationale

A wound culture is performed to identify pathogens that may be causing a non-healing wound. However, it should only be done after assessing for other potential causes, such as poor circulation, which can compromise the delivery of immune cells and antibiotics to the wound site, making it impossible for the wound to heal regardless of the presence of bacteria.

Choice C rationale

Elevating the foot may be beneficial for reducing edema if present, which can impede circulation. However, this intervention should be based on a comprehensive circulatory assessment. Without first assessing the vascular status of the leg, this action is premature and may not be the most critical first step to take in addressing the underlying problem.

Choice D rationale

Assessing the right leg for pulses, skin color, and temperature is the most critical first step. A non-healing wound on an extremity, particularly an ankle, may indicate underlying peripheral arterial disease. Inadequate blood flow compromises oxygen and nutrient delivery to the wound bed, preventing cellular repair and growth. Ruling out or identifying circulatory compromise is the initial priority.

Choice A rationale

A Braden Scale score of 9 indicates a high risk for pressure injury. Requesting a referral to a registered dietitian nutritionist is an evidence-based intervention because poor nutrition, particularly protein and calorie deficiency, is a significant risk factor for skin breakdown and impaired wound healing.

Choice B rationale

Keeping the head of the bed raised no more than 45 degrees is an evidence-based practice to prevent pressure injuries. This position reduces the risk of shear and friction forces on the sacrum, which can lead to tissue damage and pressure ulcer formation.

Choice C rationale

Performing perineal cleansing every 2 hours is not an evidence-based intervention for a Braden Scale score of 9. Frequent cleansing can cause excessive moisture, which macerates the skin and increases the risk of breakdown. Cleansing should be done as needed, not on a rigid schedule.

Choice D rationale

Daily skin assessment is a fundamental and evidence-based intervention for all clients at risk for pressure injuries. A Braden score of 9 signifies a high-risk client, and a daily head-to-toe skin assessment is crucial for early detection of erythema or other signs of skin breakdown.