A nurse is assessing a client who has a stage 3 pressure injury. Which of the following findings indicates possible infection of the wound?
Explanation & Rationale
A. Serosanguineous drainage: Serosanguineous drainage, which is a mixture of serum and blood, is common and expected in the early stages of wound healing, including stage 3 pressure injuries. It does not necessarily indicate infection. B. Granulation tissue: Granulation tissue is a sign of healthy wound healing. It appears as red, moist tissue and indicates that the wound is healing properly, so it does not suggest infection. C. Localized tenderness: Localized tenderness around the wound can be a sign of infection. Infection can cause pain, redness, warmth, and tenderness at the site of the pressure injury. It is important to monitor for other signs of infection, such as increased drainage or changes in wound color. D. Moist wound bed: A moist wound bed is generally beneficial for wound healing and does not indicate infection. In fact, keeping the wound moist helps promote granulation tissue formation and wound closure.