Problem:
Examination data ? ??General survey: Alert, very thin male with flat affect lying in a supine position. Height, 6 ft 2 in (188 cm); weight, 153 lb (69.5 kg). Slight foul-smelling odor noted. ??Skin: Skin color is pale. No evidence of bruising, no skin discoloration. Presence of stage 2 pressure injury involving the epidermis over the left greater trochanter and sacrum. ??• Hair: Full hair distribution on head with soft texture. ??Abdomen: Active bowel sounds. Abdomen soft, nondistended, nontender. ??Musculoskeletal: Paralysis, atrophy to both lower extremities; upper extremities have full range of motion and adequate muscle strength and tone. Clinical judgment
1. What cues do you recognize that suggest a deviation from normal findings, suggesting a need for further investigation?
2. For which addîtional information should the nurse ask or assess?
3. Which risk factors for pressure injury does this patient have?
4. With which interdisciplinary team members can the nurse collaborate to help meet this patient's needs?