The nurse has documented the following wound assessment: “Shallow, open, reddened ulcer with no drainage on the center of the right heel.” What stage is the wound?

Choice A reason: A temperature of 101.3 degrees Fahrenheit is a sign of fever, which is a common symptom of infection. Clients with AIDS have a weakened immune system and are more susceptible to opportunistic infections. Fever indicates that the body is trying to fight off an infection.

Choice B reason: An oxygen saturation of 97% on room air is within the normal range and does not indicate infection. Oxygen saturation measures the percentage of hemoglobin that is bound to oxygen in the blood. A low oxygen saturation may indicate respiratory problems, such as pneumonia, which is a common infection in clients with AIDS.

Choice C reason: A respiratory rate of 22 breaths per minute is slightly above the normal range of 12 to 20 breaths per minute, but it does not necessarily indicate infection. Respiratory rate may vary depending on factors such as activity level, stress, pain, or anxiety. A high respiratory rate may indicate respiratory distress, which could be caused by infection or other conditions.

Choice D reason: Purulent drainage is a thick, yellowgreen, or brown pus that indicates infection. It may come from a wound, an abscess, or a body cavity. Purulent drainage is a sign of inflammation and infection and should be reported to the health care provider.

Choice E reason: A client's ability to ambulate 20 feet is not related to infection. Ambulation is a measure of mobility and function and may be affected by factors such as pain, fatigue, or muscle weakness. Ambulation does not reflect the presence or absence of infection.

Choice A reason: Ischemia is a cause of a pressure ulcer, because it means reduced blood flow to the tissues, which can lead to tissue hypoxia, necrosis, and ulceration. Ischemia can result from factors such as compression, friction, shear, or vascular disease.

Choice B reason: Immobility is a cause of a pressure ulcer, because it means prolonged pressure on the bony prominences, which can impair blood flow and cause ischemia, tissue damage, and ulceration. Immobility can result from factors such as paralysis, injury, illness, or sedation.

Choice C reason: Poor nutrition is a cause of a pressure ulcer, because it means inadequate intake or absorption of nutrients, such as protein, calories, vitamins, and minerals, which are essential for tissue repair and wound healing. Poor nutrition can result from factors such as anorexia, malabsorption, or poverty.

Choice D reason: Moisture is a cause of a pressure ulcer, because it means excessive wetness or dampness of the skin, which can weaken the skin barrier, increase the risk of infection, and delay wound healing. Moisture can result from factors such as incontinence, perspiration, or wound drainage.

Choice E reason: Adequate perfusion is not a cause of a pressure ulcer, but rather a protective factor. Adequate perfusion means sufficient blood flow to the tissues, which can prevent ischemia, tissue damage, and ulceration. Adequate perfusion can be promoted by factors such as regular repositioning, pressure relief, and exercise.