Question

A client is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure injury on her coccyx measuring 5cm by 3cm. The nurse observes bone and tendon at the base of the wound. How would the nurse document this wound?

a) Stage 3 pressure injury
b) Unstageable pressure injury
c) Stage 4 pressure injury
d) Deep tissue injury

Answer 1

The nurse would document this wound as a Stage 4 pressure injury.

Step-by-step explanation:

The nurse would document this wound as a c) Stage 4 pressure injury. Stage 4 pressure injuries involve full-thickness skin loss with exposed bone, tendon, or muscle. In this case, the nurse observes bone and tendon at the base of the wound, indicating a Stage 4 pressure injury. Stage 4 pressure injuries are the most severe and can be life-threatening if not properly treated.