A nurse is caring for a client who has a pressure injury. Exhibits Click to highlight the documentation in the client's medical record that requires further action by the nurse. To deselect information, click on the information again. Day 4: Hydrocolloid dressing removed. Client has a 2.5 cm (1 in) x 3 cm (1.2 in) stage 3 pressure injury on left heal. Increased redness at wound borders and purulent drainage noted. Temperature 38.9° C (102° F) BP 118/56 mm Hg Heart rate 102/min Respiratory rate 22/min Pulse oximetry 95% on room air Hct 38% (37% to 47%) Hgb 12 g/dl (12 g/dL to 16 g/dL) WBC 12,000/mm (5,000 to 10,000 mm)