Question

A nurse is performing a skin assessment on a client who has a wound on their heel that is blistered and lighter in color than the client's skin tone. The nurse should identify that the wound is in which of the following stages of damage?

A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4

Answer 1

The wound with blistering on the heel in lighter color is a Stage 2 injury, affecting both the epidermis and dermis layers of the skin. Careful wound management is needed for healing, including keeping the burn site clean and sterile. This knowledge helps provide appropriate treatment for skin injuries.

Step-by-step explanation:

The nurse should identify that the wound on the heel with blistering and lighter color than the client's skin tone is in Stage 2 of damage. In Stage 2, the damage affects both the epidermis and a portion of the dermis, which results in swelling and painful blistering of the skin. This stage is characterized by an open wound or blister with a red-pink wound bed, without slough or bruising. Proper wound care involves keeping the burn site clean and sterile to prevent infection, and with this care, the burn should heal within several weeks.

To further support the recovery process after initial clot formation, the next healing response by the body would involve inflammation and the recruitment of various cells to the site of injury to begin tissue repair and fight off any potential infection. Stages of burns, such as first-degree through fourth-degree, are significant when assessing the severity of damage to the skin and selecting the appropriate treatment strategy.