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.