The nurse is turning a patient when she notices an area with nonblanchable redness over the patient's coccyx.The patient complains of pain at the site,and the site does feel cooler than the areas immediately around the site.The nurse recognizes that this patient has developed:

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The hallmarks of a stage I pressure ulcer are intact skin with nonblanchable redness of a localized area,usually over a bony prominence.The area may be painful,firm,soft,and warmer or cooler as compared with adjacent tissue.
Stage II pressure ulcers are defined by partial-thickness loss that presents as a shallow open ulcer with a red or pink wound bed,without slough.It also may present as an intact or open/ruptured serum-filled blister.It usually presents as a shiny or dry shallow ulcer without sloughing or bruising.Unstageable pressure ulcers are characterized by full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow,tan,gray,green,or brown)and/or eschar (tan,brown,black)in the wound bed.Until enough slough and/or eschar is removed to expose the base of the wound,the true depth,and therefore the stage,cannot be determined.Deep tissue injury usually is characterized by purple or maroon localized areas of discolored intact skin or blood-filled blisters caused by damage of underlying soft tissue from pressure and/or shear.The area may be preceded by tissue that is painful,firm,mushy,boggy,and warmer or cooler as compared with adjacent tissue.The wound may further evolve and become covered by thin eschar.

The Nurse Is Turning a Patient When She Notices an Area