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Signs of infection include increasing erythema, purulent drainage, swelling, worsening pain, and a temperature greater than 100.4°F. The patient's symptoms do not meet the criteria for infection.

Impending dehiscence is often signaled by sudden drainage of large amounts of serosanguineous fluid, separation of wound edges, or visible underlying tissue. These signs are not present in this case.

Notifying the physician is not necessary at this time since the findings are within expected postoperative parameters. Routine monitoring is appropriate unless changes occur

Serum protein analysis evaluates nutritional status and protein levels (e.g., albumin), which can affect wound healing, but it does not directly assess for systemic infection or inflammation.

A punch biopsy can provide histological information about chronic wounds, especially if malignancy or atypical causes are suspected, but it is not routinely used to assess systemic response.

Culture and sensitivity are used to identify the causative organism at the wound site and guide antibiotic therapy but do not measure the body’s systemic response to infection.

A cooling blanket may be used for very high fevers, but it can cause shivering, which increases metabolic demand and discomfort. It is typically reserved for heatstroke or when antipyretics are ineffective.

Increased fluids and sponge baths help with hydration and comfort but do not directly affect the hypothalamic temperature regulation set point. These are supportive measures, not primary interventions.

Antibiotics treat the underlying cause if the fever is due to a bacterial infection, but they do not directly reduce fever. Warm blankets may provide comfort during chills but will not help reduce body temperature.

Tertiary intention healing (also called delayed primary closure) involves initially leaving a wound open due to contamination or infection risk, then surgically closing it later. This is not typical for pressure ulcers managed conservatively.

Regeneration of cells refers to the replacement of lost cells with the same type of cells (as in superficial skin wounds or liver tissue), but pressure ulcers usually involve deeper tissue layers requiring granulation and scarring.

Remodeling of tissues is the final phase of wound healing, not the type or process of healing. It involves strengthening of collagen and scar formation after the wound has closed.

While imbalanced nutrition contributes to poor healing, in this case it is not the most immediate or primary barrier. The necrosis and need for amputation point to severely compromised circulation as the priority.

Impaired tissue integrity reflects the wound’s condition, but it does not directly address the underlying cause of poor healing. A diagnosis focusing on perfusion is more appropriate and foundational.

Coping may be an issue, but addressing physiological needs like perfusion takes priority in wound healing and surgical recovery

Packing with foam dressing is appropriate for stage III ulcers, which may have depth requiring absorbent and conformable dressings that maintain moisture and fill dead space.

Turning and positioning every 2 hours is a critical intervention to prevent worsening of pressure ulcers and support healing by reducing pressure on affected areas.

Pain assessment and pre-medication before dressing changes are standard practice to improve patient comfort and compliance with wound care.

DuoDerm is typically used to protect areas at higher risk or to treat existing ulcers. It may be appropriate later but is not the first-line preventive action for a score of 16.

Elevating the head of bed to 90 degrees increases pressure and shear on the sacrum and is contraindicated in patients at risk for skin breakdown.

Weekly skin assessments without any special precautions are inadequate for someone with a moderate risk. Regular assessment and repositioning are essential.

Stage I involves intact skin with non-blanchable erythema—there is no open wound or tissue loss.

Stage II includes partial-thickness loss of dermis and presents as a shallow open ulcer, but subcutaneous tissue is not exposed.

Stage IV includes full-thickness tissue loss with exposed bone, tendon, or muscle—none of which are visible in this case.

Shining light on the wound and eliciting history are not part of RICE and do not address immediate injury management.

Rubbing the wound clean is inappropriate and can cause further tissue damage. Exercising the leg immediately after injury can worsen it.

Rinsing the wound and imaging may be needed but are not components of the RICE protocol. Carrying and extending the ankle are also not appropriate immediate interventions.

Inflammation lasting 2 to 3 weeks is more typical of subacute or acute inflammation, not chronic.

Infective endocarditis may have both acute and chronic features but is not exclusively a classic example of chronic inflammation.

Neutrophils dominate in acute inflammation; chronic inflammation is characterized more by macrophages, lymphocytes, and plasma cells.

Secondary healing does not always require surgical debridement; it depends on wound condition.

Primary healing involves suturing the edges of a clean wound, not suturing granulation tissue.

Secondary intention takes longer, but the main difference is the amount of granulation tissue and scarring, not merely the number of healing steps

Serosanguineous drainage is usually seen in clean, healing wounds and is more associated with red wounds.

Adherent gray necrotic tissue describes a black wound with eschar, not a yellow wound.

Clean, moist granulating tissue is characteristic of a red wound, indicating healthy healing tissue.

Although obesity and diabetes increase risk factors for complications, the patient’s mobility is likely better preserved compared to a comatose patient.

Advanced age, confusion, and malnutrition increase risk but a comatose state generally presents a more immediate and severe risk due to total immobility.

Incontinence increases moisture-related skin breakdown but is less critical compared to the immobility and sensory loss in coma

The wound is not cleaned daily; the dressing changes and wound care follow specific protocols, often less frequently than daily.

Hyperbaric oxygen therapy is a separate treatment and not part of wound vac therapy.

Nutrition remains critically important for wound healing, even when using wound vac therapy