A dark-complexioned African American has a suspected skin breakdown over the trochanter. What would be appropriate measures for the nurse to implement during the assessment? (Select all that apply.)
a. Use a halogen light to examine the area.
b. Palpate for local edema in the area.
c. Touch the area to feel for changes in tissue temperature.
d. Assess for localized pain.
e. Press the area to test for blanching.
ANS: A, B, C
Halogen lights make a stage I area appear blue in a dark-skinned person. There is usually a local area of heat and edema. Stages I and II pressure ulcers are painless. Testing for blanching when erythema cannot be assessed is useless.
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