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The nurse is doing a body audit on a client who is immobile…

The nurse is doing a body audit on a client who is immobile and notes that an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. The most appropriate nursing action at this time is to:

The nurse is caring for a 68 year old wheelchair bound male…

The nurse is caring for a 68 year old wheelchair bound male who has come to the clinical with his daughter for a routine checkup. Nurses’ Notes:  1000: Client received for a routine checkup accompanied by daughter with whom he lives. Client has paraplegia secondary to spinal cord injury. Client is alert and oriented x4. Denies pain or any problems. Daughter is concerned about “red area on his left heel.”  VS 97.9F-76-16-112/68 Lungs clear, S1S2 audible with no murmurs, gallops, rubs. Bowel sounds hypoactive. Full range of motion in bilateral upper extremities with light touch sensation intact in fingers. No feeling or movement below waist. Full passive ROM bilaterally in lower extremities. Open area noted on left heel – foul odor detected. Skin otherwise intact.  1015: Left heel wound measures 3.5cmx4c.x1cm. No undermining present. Wound bed is pink with small amount white subcutaneous tissue noted. Slight foul odor detected. No drainage noted. Skin surrounding injury pink, warm, and dry. Provider and wound nurse notified of wound. 1030: Wound nurse here to assess left heel wound. Confirms stage III pressure injury.  For each potential order below, specify whether the order is indicated or contraindicated to include in the plan of care.