The nurse is cаring fоr а 68 yeаr оld wheelchair bоund male who has come to the clinical with his daughter for a routine checkup. Nurses' Notes: 1000: Client received for a routine checkup accompanied by daughter with whom he lives. Client has paraplegia secondary to spinal cord injury. Client is alert and oriented x4. Denies pain or any problems. Daughter is concerned about "red area on his left heel." VS 97.9F-76-16-112/68 Lungs clear, S1S2 audible with no murmurs, gallops, rubs. Bowel sounds hypoactive. Full range of motion in bilateral upper extremities with light touch sensation intact in fingers. No feeling or movement below waist. Full passive ROM bilaterally in lower extremities. Open area noted on left heel - foul odor detected. Skin otherwise intact. 1015: Left heel wound measures 3.5cmx4c.x1cm. No undermining present. Wound bed is pink with small amount of white subcutaneous tissue noted. Slight foul odor detected. No drainage noted. Skin surrounding injury pink, warm, and dry. Provider and wound nurse notified of wound. 1030: Wound nurse here to assess left heel wound. Confirms stage III pressure injury. New orders: Cleanse left heel with normal saline and complete wet to dry dressings every 6 hours. Return in two weeks for follow up. Progress notes: Seen in clinical for follow up on stage III pressure injury diagnosed 15 days ago. Wound measures 3cmx3.7cmx0.5cm. No odor, drainage, or signs of infection. Skin surrounding wound remains pink, dry, and intact. Complete the following sentence by choosing the correct letter (A, B, or C) from the list of options. The nurse determines the client's status is _______ A. improving B. deteriorating C. unchanged The nurse should now _______ A. Call the wound care nurse to discuss a change in the treatment plan. B. Recommend the use of a vacuum assist wound closure system. C. Reinforce wound care intervention and pressure injury prevention strategies with the client and daughter.
Which оf the fоllоwing muscles is primаrily responsible for hip flexion?