When assessing a patient's pressure ulcer, the nurse finds that it is 3 cm in diameter and 1 cm deep and has tunneling on the left side. The ulcer holds 17 mL of normal saline. There is no visible fascia or bone in the ulcer. What pressure ulcer stage should the nurse document?

Question

Quizplus · Accepted Answer

The ulcer is 3 cm in diameter and 1 cm deep, indicating tissue destruction through the subcutaneous fat layer. The presence of tunneling on the left side also indicates deeper tissue damage. The ulcer also holds 17 mL of normal saline, indicating moderate drainage. The absence of visible fascia or bone means that the ulcer has not reached stage 4.

When Assessing a Patient's Pressure Ulcer, the Nurse Finds That