The nurse is collecting data for a patient who has a developing pressure ulcer. Which of the following would the nurse expect to identify as early manifestations of a pressure ulcer? (Select all that apply.)
a. Report of redness at the site
b. Report of burning at the site
c. Coolness of site to touch
d. Cyanosis of site observed
e. Tenderness at site when touched
f. Report of decreased sensation at site
ANS: A, B, E
Early signs of pressure ulcer formation are warmth, redness, tenderness, and a burning sensation at the potential ulcer site.
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