An older adult patient with diabetes recently moved into an assisted living apartment to have assistance with bathing and housework.During a bath,the assistive nursing personnel noticed that there was a large blister on the patient's right heel.The patient denies knowledge of having injured self.It was reported to the nurse who correctly documented it as what stage of a pressure ulcer?

Question

Quizplus · Accepted Answer

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 I: Intact skin with nonblanchable redness of a localized area,usually over a bony prominence
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

An Older Adult Patient with Diabetes Recently Moved into an Assisted