A nurse is caring for a client in a medical-surgical unit.
Exhibit 1
Exhibit 2
History and Physical
3 days ago:
Current diagnoses: type 2 diabetes mellitus
Past medical history: left below-the-knee amputation 5 years ago.
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0830:
At client's bedside 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 mmHg. Client reports pain as a 2 on a scale from 0 to 10, tolerated procedure well.