Question

A head-to-toe skin assessment is done per institutional policy each shift or on a daily basis. At the most recent assessment of Mrs. Stein's ski, blistering was noted over the sacral area; on direct examination it was a small area of denuded tissue with redness around the blistered area. The area was found to have minimal depth and a red, moist, base. How would you describe the impairment in skin integrity in your charting?

Answer 1

The impairment in skin integrity described in the charting would be classified as a stage II pressure ulcer.

Step-by-step explanation:

The impairment in skin integrity described in the charting would be classified as a stage II pressure ulcer. A pressure ulcer, also known as a bed sore, occurs when there is prolonged pressure on the skin, leading to tissue damage. In this case, the blistering, denuded tissue, redness, and minimal depth suggest that the ulcer has reached stage II.

Stage II pressure ulcers involve partial-thickness loss of skin layers. The skin may appear as a shallow, open blister or as a shallow, open ulcer with a red, moist base. It is important to assess and document the size, location, and characteristics of the ulcer for proper treatment. It is crucial to mention the specific location, characteristics of the wound base, exudate (if any), signs of infection, and the size of the wound.