Question

The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage has occurred to the subcutaneous tissues; how would she document this wound?

A) Stage I pressure ulcer
B) Stage II pressure ulcer
C) Stage III pressure ulcer
D) Stage IV pressure ulcer

Answer 1

The wound on the client's leg with damage to subcutaneous tissues would be documented as a Stage III pressure ulcer.

Step-by-step explanation:

The classification of pressure ulcers is based on the depth of tissue damage observed. Given that damage in this scenario has occurred to the subcutaneous tissues, it would classify as a Stage III pressure ulcer. Stage I involves non-blanchable erythema of intact skin indicating damage to the underlying tissue. Stage II is an open ulcer with partial thickness skin loss or a blister. Stage III encompasses full thickness skin loss involving damage to or necrosis of subcutaneous tissue. Stage IV is more severe, showing extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.