A nurse is performing an admission physical examination on a patient who has been bedridden for a month. The nurse notices a pressure ulcer on the patient's left trochanter area that involves partial-thickness skin loss with damage to the subcutaneous tissue. The nurse reports this ulcer at what stage?

Question

Quizplus · Accepted Answer

Stage II ulcers have partial-thickness skin loss of dermis. It appears as a shiny or dry shallow open ulcer with pink wound bed without slough or bruising. Stage I ulcers have persistent redness, but the epidermis is intact. Stage III ulcers have full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend to, but not through, underlying fascia. Stage IV ulcers have full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be within the wound bed.

A Nurse Is Performing an Admission Physical Examination on a Patient