Question

A client with type 1 diabetes mellitus has a blister on the left heel that resulted from improperly fitting shoes. The nurse should document this ulcer as being which stage?

1) Stage IV
2) Stage III
3) Stage II
4) Stage I

Answer 1

The diabetic patient's blister on the heel from improperly fitting shoes should be documented as a Stage II ulcer, which indicates partial thickness loss of dermis.

Step-by-step explanation:

The blister on a patient with type 1 diabetes mellitus that resulted from improperly fitting shoes should be documented as a Stage II ulcer. This stage is characterized by partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. Furthermore, this may also present as an intact or open/ruptured serum-filled blister. Given that the description does not mention any exposure of subcutaneous tissue, muscle, tendon, bone, or support structures, which would correspond to higher stages, Stage II is the most appropriate classification for this condition.