The nurse is assessing the heel of a patient with quadriplegia. When the nurse applies gentle pressure to the skin on the heel, it is non-blanchable and erythematous. The nurse would document this as a:

Non-blanchable erythema of intact skin is the hallmark of a Stage 1 pressure injury. When pressure is applied to healthy skin, it momentarily turns white (blanches) because blood is pushed out of the capillaries; when that blanching response is absent and redness persists, it indicates that superficial tissue damage has already begun, even though the skin surface remains intact. This is precisely the definition of a Stage 1 pressure injury according to the National Pressure Injury Advisory Panel staging system. The heel is a high-risk bony prominence, particularly in patients with quadriplegia who cannot reposition themselves and may have impaired sensation. A Stage 2 pressure injury involves partial-thickness skin loss, presenting as an open shallow ulcer or intact or ruptured blister — there is no open wound described here. A Stage 4 pressure injury involves full-thickness tissue loss with exposed bone, tendon, or muscle, which is far more severe than what is described. Documenting this as normal expected findings would be incorrect and dangerous because non-blanchable erythema signals early tissue damage requiring immediate offloading and pressure redistribution interventions. Identifying Stage 1 injuries early is critical because prompt intervention can prevent progression to more severe and difficult-to-heal wounds.