The nurse is assessing a wound on the medial surface of a patient's left foot. Which of the following assessment findings would indicate that the patient is exhibiting signs of inflammation? (Select all that apply.)
1. Imprint of the patient's sock is visible above ankle
2. Reports pain of 7/10 at site of wound
3. Erythema is present around wound
4. Skin from ankle to toes is cool to the touch
5. Pedal pulse is weaker in the left foot
Correct
• Imprint of the patient's sock is visible above ankle
• Reports pain of 7/10 at site of wound
• Erythema is present around wound
Rationale: Imprint of the patient's sock is visible above ankle. The imprint of the patient's sock at the ankle is likely due to edema in the foot. Reports pain of 7/10 at site of wound. Pain is caused by pressure on the local nerve endings. Erythema is present around wound. Erythema is caused by increased blood flow to the area. Skin from ankle to toes is cool to the touch. The skin would be warm, not cool, to touch. Pedal pulse is weaker in the left foot. A weak pedal pulse in the foot could indicate something other than an inflammatory response.
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