A nurse is assessing a client's coccyx area and notes visible subcutaneous fat with tunneling. Which of the following pressure injury stages should the nurse document?

Rationale for correct choices

• Pulmonary embolism: The client exhibits sudden onset of dyspnea, chest discomfort, tachypnea, hypoxemia (oxygen saturation 92% on 2 L O₂), and appears in respiratory distress, all of which are classic signs of a pulmonary embolism. Postoperative orthopedic patients, especially after hip arthroplasty, are at high risk due to immobility, venous stasis, and hypercoagulability.

• Recent surgery: The client’s recent total hip arthroplasty increases the risk of thromboembolic events. Surgical procedures, particularly major orthopedic surgeries, create a hypercoagulable state and contribute to venous stasis, which can precipitate a pulmonary embolism.

Rationale for incorrect choices

• Pneumothorax: Pneumothorax typically presents with unilateral chest pain, sudden shortness of breath, and decreased or absent breath sounds on one side. The client’s crackles are bilateral and S3/S4 heart sounds are present, which are not consistent with pneumothorax.

• Pneumonia: Although the client has fever and crackles, the sudden onset of symptoms and acute respiratory distress are more consistent with pulmonary embolism rather than pneumonia, which usually develops gradually. Additionally, the timing shortly after surgery favors a thromboembolic event over an infectious process.

• Tobacco use: The client reports no history of tobacco use, making this an irrelevant risk factor for the current acute episode.

• Activity level: While immobility can contribute to thrombus formation, the client ambulated with assistance earlier, and the more significant risk factor remains recent surgery, which directly predisposes to pulmonary embolism.

A. Abdomen: The abdomen is typically used for subcutaneous injections, such as insulin or heparin, due to its fatty tissue. It is not ideal for intradermal injections, which require a thin layer of skin to allow for proper absorption and observation of a wheal.

B. Deltoid: The deltoid muscle is commonly used for intramuscular injections, not intradermal ones. Using this site for intradermal injections could result in the medication being deposited too deeply, affecting absorption and test accuracy.

C. Back of the upper arm: The inner surface of the forearm or the back of the upper arm is the preferred site for intradermal injections, such as tuberculosis or allergy testing. This area has thin skin, minimal subcutaneous fat, and allows for easy visualization of the wheal and monitoring for reactions.

D. Upper back: While the upper back has subcutaneous tissue, it is not commonly used for intradermal injections because it is less accessible for observation and assessment of local reactions. Proper site selection is important for safety and effectiveness.