The nurse notes a reddened area on the right heel that does not turn lighter in color when pressed with a finger.
Which term will the nurse use to describe this area?
A.
Secondary erythema.
B.
Nonblanchable erythema.
C.
Blanchable hyperemia.
D.
Reactive hyperemia.
The Correct Answer and Explanation is:
The correct answer is B. Nonblanchable erythema.
Explanation:
When assessing skin integrity, particularly in patients at risk for pressure injuries, the observation of skin color changes in response to pressure is crucial. The term “nonblanchable erythema” is used to describe a reddened area of the skin that does not lighten when pressed with a finger. This is a key indicator of potential skin damage or pressure ulcer development.
Nonblanchable erythema is a term used specifically in the context of pressure ulcers (also known as pressure injuries or bedsores). It refers to a localized area of redness that persists even after the application of pressure. This type of erythema indicates that the underlying tissues are at risk or already damaged, and it often represents the initial stage of a pressure ulcer (Stage I pressure injury). Nonblanchable erythema is characterized by an area of redness that does not change color when pressed, as opposed to blanchable erythema, where the redness fades under pressure.
In contrast, blanchable hyperemia (option C) refers to an area of redness that temporarily fades when pressure is applied and then returns once the pressure is removed. This condition usually indicates that the skin has not sustained permanent damage and is often seen in the early stages of pressure-related injuries where the tissue is still responsive to pressure.
Secondary erythema (option A) is not a standard term used to describe skin conditions in the context of pressure ulcers. It may be used to describe skin redness secondary to other conditions, such as an allergic reaction or infection, but it is not specific to the pressure ulcer terminology.
Reactive hyperemia (option D) refers to the redness of the skin that occurs after the release of pressure. It indicates a temporary increase in blood flow to the affected area, typically resolving once the pressure is removed, and it is not a sign of permanent tissue damage.
In summary, nonblanchable erythema is the appropriate term for describing a reddened area on the skin that does not lighten when pressed, indicating possible underlying tissue damage and a higher risk for pressure ulcer development.