1020: Client presented to the clinic via wheelchair for a routine evaluation, accompanied by father, who is also the primary caregiver. The client has a history of paraplegia secondary to cervical spinal cord injury. Client is alert and oriented to person, place, and time. Peripheral pulses 2+. Lung sounds clear bilaterally. Abdomen taut with normoactive bowel sounds. Skin warm, dry, and moist. Father voices concern regarding a “red area” noted on the client’s left heel.

1049: Wound identified on the left heel.

3.2 cm (length) × 4 cm (width) × 0.5 cm (depth)

Wound bed was pink, no slough, granulation, or eschar

Wound edges are well defined

No undermining or tunneling

Surrounding skin was normal for ethnicity, warm, and dry

Scant serous drainage

Temperature 97.9°F (36.6°C)

Pulse 67 bpm

Respirations 18/min

Blood pressure 138/71 mm Hg

Pulse oximetry 95% on room air