Question

A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as?

1)
Stage II pressure ulcer
2)
Stage III pressure ulcer
3)
Stage IV pressure ulcer
4)
Unstageable pressure ulcer

Answer 1

The pressure area with 100% eschar on the coccyx is classified as an unstageable pressure ulcer because the true depth of the wound cannot be determined until the eschar is removed.

Step-by-step explanation:

The patient with a pressure area on her coccyx covered with 100% eschar would be identified as having an unstageable pressure ulcer. An unstageable pressure ulcer is one where the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the wound bed. Due to the presence of eschar, the true depth, and therefore the stage, cannot be determined. Until enough eschar is removed to expose the base of the wound, it cannot be categorized as Stage II, Stage III, or Stage IV.