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."
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.
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