Mr. Snape, a 73 year old widower, has been living alone for the past 5 months. He has been adjusting to help himself since his wife would usually be of great assistance. Mr. Snape has fallen back on...

As a nurse what is the first steps you would take to indicate Risk for infection related to open pressure ulcer

Extracted text: Mr. Snape, a 73 year old widower, has been living alone for the past 5 months. He has been adjusting to help himself since his wife would usually be of great assistance. Mr. Snape has fallen back on his care routine and unfortunately developed a skin ulcer on his upper left sacral area. He explained that it started off quite small but due to the lack of knowledge on how to treat an ulcer, it began to get worse and became painful. Later that afternoon Mr. Snape was admitted to the accident and emergency department for a stage three pressure ulcer. He verbalized that he has been diabetic for 15 years and has a PMH of right leg amputation by 6 months. He states that he takes metformin 850mg orally once a day. Also due to his severe pain, he rated it to be 8/10 on the pain scale, and also indicated that he took 2 panadol ultra. His vital signs were as follows: BP- 130/80 Temp- 36.9 degrees celsius RBS- 123 mg/dl.