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Original Question
urses’ Notes Three days ago, 1000: Client admitted from home reports a pressure injury. Provider and wound care nurse at bedside. Slough and eschar covering pressure injury on sacrum. Debridement performed. Malodorous. Pressure injury stage 4 with two tunnels present. Pressure injury is 10 cm (4 in) in diameter and 3 cm (1.2 in) at the deepest point. Tunneling locations at one and eight o’clock and measure at 6 cm (2.4 in) and 4 cm. (1.6 in) respectively. Wound care nurse initiated negative pressure wound therapy. Today 0800: Client sitting in bed, alert, and oriented x4. Client states, “I can’t wait to get this thing off of me.” States pain is a 5 on a scale of 0 to 10. PRN analgesic prescribed. 0830: At client’s beside for dressing change. S1 and S2 auscultated, rate 76/min. Respirations even and regular at 16/min. Negative pressure wound therapy dressing removed. Granulation tissue covers the wound bed. Slight erythema at wound edges. The surrounding tissue is warm to touch. No odor present. Pressure injury is 8.75 cm (3.5 in) in diameter and 2.5 cm (1 in) at the deepest point. Two tunnels measuring 5 cm (2 in) and 3 cm (1.2 in). Dressing reapplied and sealed, intermittent pressure setting at 125 mm Hg. Client reports pain as a 2 on a scale from 0 to 10, tolerated procedure well Click to highlight the findings that indicate an improvement in the client’s condition. To deselect a finding, click on the finding again. At client’s beside for dressing change. S1 and S2
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