A nurse is performing a skin assessment on an elderly patien…

A nurse is performing a skin assessment on an elderly patient who has been hospitalized for a week. The patient is at high risk for pressure ulcers due to immobility and poor nutritional status. During the assessment, the nurse notes redness and warmth over the patient’s heels, with non-blanchable erythema. Based on clinical judgment, which of the following actions should the nurse take? Select all that apply.