A nurse in a post-anesthesia care unit (PACU) is assessing a patient who has a newly created colostomy. What findings should the nurse report to the provider?

Choice A rationale

Increased collagen is not a factor that would lead to a pressure injury in a client with impaired mobility. Collagen is a protein that helps in the formation of skin and other connective tissues.

Choice B rationale

Decreased serum calcium is not directly related to the development of pressure injuries. While calcium is important for bone health and muscle function, it does not play a direct role in skin integrity.

Choice C rationale

Increased muscle mass is not a risk factor for pressure injuries. In fact, good muscle mass can help distribute pressure more evenly and potentially reduce the risk of pressure injuries.

Choice D rationale

Decreased circulation is a major risk factor for the development of pressure injuries. When blood flow to an area of the body is reduced, the tissues in that area can become deprived of oxygen and nutrients, leading to cell death and the formation of pressure injuries.

The client is at greatest risk for developing a Pressure ulcer due to Limited mobility.

The client’s limited mobility and the need for assistance to turn and transfer out of bed increases the risk of pressure ulcers. Pressure ulcers, also known as bedsores, are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin. They most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone. People most at risk of pressure ulcers are those with a medical condition that limits their ability to change positions or those who spend most of their time in a bed or chair.