The nurse is admitting a client with a pressure ulcer to the long-term care facility.When assessing the wound,the nurse finds partial-thickness skin loss free of eschar.Which stage will the nurse document this ulcer as based on the assessment data?

Question

Quizplus · Accepted Answer

Partial-thickness skin loss without exposed bone, tendon or muscle is classified as a Stage II pressure ulcer. Stage I indicates intact skin with non-blanchable redness, while Stage III and IV involve deeper tissue involvement with full thickness skin loss and potential muscle or bone involvement.

The Nurse Is Admitting a Client with a Pressure Ulcer