Question

the nurse is admitting a patient from a long term care facility. during the assessment, the nurse notes a shallow open pressure injury without slough on the right heel of the patient. how would this pressure injury be staged?

Answer 1

A shallow open pressure wound without slough on a patient's heel would likely be classified as a Stage II pressure ulcer. This type of injury usually appears as an open wound or blister and is often seen in immobile patients, due to unrelieved pressure causing loss of blood flow and tissue death (necrosis).

Step-by-step explanation:

The pressure injury you're describing on the patient's right heel would most likely be staged as a Stage II pressure ulcer. A Stage II pressure ulcer is characterized by a shallow open wound or blistering without slough or bruising. Since the tissue loss in this stage only extends to the dermis (the second layer of skin), the wound often looks like a scrape (abrasion), blister, or shallow crater. Such pressure ulcers are often caused by unrelieved pressure on the skin, reducing blood flow and leading to tissue death (necrosis). It's commonly seen in immobile patients, such as those in long-term care facilities. Intensive wound care is necessary to prevent the ulcer from progressing to more severe stages.

Learn more about Pressure Ulcer Staging