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

A wound with damage to the subcutaneous tissues in a diabetic patient should be documented as a Stage III pressure ulcer.

Step-by-step explanation:

If a wound care clinical nurse specialist evaluates a wound on the leg of a client with diabetes and determines that damage has occurred to the subcutaneous tissues, this type of wound would be documented as a Stage III pressure ulcer. Stage III pressure ulcers are characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of the adjacent tissue.