Question

A nurse is caring for a client who had a spinal cord injury and has paraplegia.

The nurse is reviewing the client's medical record.
Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again.

Nurses' Notes
Day 1:
Client is alert and oriented.
Client is repositioned every 2 hr.
Passive range-of-motion exercises to lower extremities performed once each day.
Day 5:
Client is alert and oriented.
Client is repositioned every 2 hr.
Passive range-of-motion exercises to lower extremities performed once each day.
Feet warm. Pedal pulses 2+ bilaterally.
Plantar flexion contractures noted bilaterally.
Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact.


A. Client is repositioned every 2 hr.
B. Passive range-of-motion exercises to lower extremities performed once each day.
C. Feet warm. Pedal pulses 2+ bilaterally.
D. Plantar flexion contractures noted bilaterally.
E. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact.

Answer 1

The findings that require intervention by the nurse are:

• D. Plantar flexion contractures noted bilaterally.
• E. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact.

Why is this the case?

These findings indicate a risk for pressure injury development and require prompt intervention.

Plantar flexion contractures: This finding indicates muscle shortening in the ankles, which can lead to pressure ulcers and other complications. The nurse should implement interventions to prevent further contracture and promote ankle flexibility.

Nonblanchable erythema: This finding suggests a pressure injury in its early stages. The nurse needs to take immediate action to offload the pressure and prevent further tissue damage.