
In assessing the skin condition of an older adult patient, the nurse notes that, over the sacral area, there is a 2 cm * 3 cm area that is reddened, does not blanch around the perimeter, and is open at the center. The most effective documentation would be:
A) "Patient has stage II ulcer on sacrum. No blanching of perimeter."
B) "Reddened area over sacrum, skin open in center."
C) "Pressure ulcer on sacrum. Massaged with no improvement in color."
D) "2 cm * 3 cm reddened area on sacrum with open center. Does not blanch."
Correct Answer:
Verified
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