Question

The nurse documented the following wound assessment: Shallow, open, reddened ulcer with no slough on the anterior region of the right heel? What stage is the wound?

A) Stage 1
B) Stage 2
C) Stage 3
D) Unstageable

Answer 1

The wound described is a Stage 2 wound.

Step-by-step explanation:

The wound described in the question is a Stage 2 wound.

In Stage 2 wounds, the injury has progressed beyond the superficial layers of the skin and may involve the dermis or subcutaneous tissue. The wound appears as a shallow, open ulcer with a red or pink wound bed and may have some drainage or necrotic tissue.

In this case, the wound is described as shallow, open, and reddened, which aligns with the characteristics of a Stage 2 wound. The absence of slough on the anterior region of the right heel further supports this classification.