A middle-age adult paraplegic patient has been admitted for follow-up from a traumatic brain injury received while serving in Afghanistan.The admitting diagnosis is failure-to-thrive.On admission,the patient was found to have a wound on the right scapula.The nurse noted full-thickness tissue loss with tunneling,but did not note any bone,tendon,or muscle.This was correctly identified as what stage of a pressure ulcer?

Question

Quizplus · Accepted Answer

Stage III: Full-thickness tissue loss; subcutaneous fat may be visible,but bone,tendon,or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling
Stage I: Intact skin with nonblanchable redness of a localized area,usually over a bony prominence
Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed,without slough; may also present as an intact or open/ruptured serum-filled blister
Stage IV: Full-thickness tissue loss with exposed bone,tendon,or muscle; slough or eschar may be present; often includes undermining and tunneling

A Middle-Age Adult Paraplegic Patient Has Been Admitted for Follow-Up