Which of the following nursing documentation best reflects the observa

Which of the following nursing documentation best reflects the observable assessment of skin breakdown on the heel of an African American client?

1. “2-cm area of scaly, dry skin located on the client’s right heel.”
2. “2-cm area of nonblanching erythema located on the client’s right heel.”
3. “2-cm area purplish blue in color surrounded by lighter-colored skin located on right heel.”
4. “2-cm area of blanching erythema located on the client’s right heel; entire foot warm to the touch.”

ANSWER

ANS: 3
In dark-skinned individuals areas of pressure appear darker than surrounding skin and have a purplish/bluish hue; the temperature of the area may be warm or cool to the touch. The remaining options use descriptives not applicable to the dark-skinned individual or less definite indicators.