A preschool paraplegic patient with cerebral palsy is admitted to the hospital with complications from the H1N1 virus.The admitting nurse notes that an area of redness on the right malleolus is nonblanchable.The nurse correctly identifies this pressure ulcer at what stage?

Question

Quizplus · Accepted Answer

Stage I: Intact skin with nonblanchable redness of a localized area,usually over a bony prominence
Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed,without slough; may also present as an intact or open/ruptured serum-filled blister
Stage III: Full-thickness tissue loss; subcutaneous fat may be visible,but bone,tendon,or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling
Stage IV: Full-thickness tissue loss with exposed bone,tendon,or muscle; slough or eschar may be present; often includes undermining and tunneling

A Preschool Paraplegic Patient with Cerebral Palsy Is Admitted to the Hospital