An 82-year-old woman, a bedbound nursing-home resident with advanced dementia, is assessed for a sacral wound first noted by nursing staff 1 week ago. She is incontinent of urine and stool, eats little, and has lost 4 kg over 3 months. History includes type 2 diabetes (HbA1c 7.6%) and hypertension. She currently lies on a standard foam mattress, is turned irregularly, has a ring cushion placed under the sacrum, and the head of the bed is kept at 60 degrees. On examination, over the sacrum there is a 3 cm x 2 cm full-thickness skin defect with visible subcutaneous fat; about 30% of the base is covered by adherent yellow slough. Bone, tendon, and muscle are not exposed. There is moderate serous drainage, and no surrounding erythema, warmth, induration, or purulence.
| Heart rate | 76/min |
| Respiratory rate | 16/min |
| Temperature | 36.9 °C |
| O2 saturation | 95%, room air |
| Blood pressure | 118/68 mm Hg |
Question 1 of 3
Which of the following measures are the most appropriate to prevent worsening of this wound and new pressure injuries?
Select 2. (0 / 2 selected)
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