Question

A patient's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer?

a. Stage I
b. Stage II
c. Stage III
d. Stage IV

Answer 1

A superficial pressure ulcer that appears as an abrasion, blister, or shallow crater should be documented as a Stage II pressure ulcer by the nurse.

Step-by-step explanation:

If a patient's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater, the nurse would document this pressure ulcer as a Stage II ulcer. This classification is consistent with the stages of pressure ulcers, where Stage II represents partial thickness loss of dermis and presents as a shallow open ulcer with a red-pink wound bed without slough.

Whereas Stage I is intact skin with non-blanchable redness, Stage III involves full-thickness tissue loss with possible visible subcutaneous fat, and Stage IV represents full-thickness tissue loss with exposed bone, muscle, or tendon.