During a skin integrity assessment, a nurse notices an area on the right heel that is black and draining purulent, foul-smelling exudate.How should the nurse document this as a pressure ulcer?

Question

Quizplus · Accepted Answer

The description of the wound indicates that it is a Stage IV pressure ulcer, as it involves full thickness tissue loss with exposed bone, tendon, or muscle and may have slough or eschar present. The presence of purulent, foul-smelling drainage suggests infection and complicates the treatment and healing process.

During a Skin Integrity Assessment, a Nurse Notices an Area