Question

A client has a pressure ulcer on the sacrum. While assessing it, the nurse observes that it has partial thickness, loss of dermis, and a red-pink wound bed. Which stage will the nurse assign this pressure ulcer?

1) Stage III
2) Stage II
3) Stage I
4) Stage IV

Answer 1

The nurse should categorize the pressure ulcer with partial thickness and loss of dermis presenting as a red-pink wound bed as a Stage II pressure ulcer, which indicates an open wound without slough.

Step-by-step explanation:

The nurse will assign the pressure ulcer on the sacrum, which has partial thickness, loss of dermis, and a red-pink wound bed, as Stage II. In Stage II pressure ulcers, the skin is broken with partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.

Stage III and Stage IV ulcers involve full-thickness tissue loss with Stage III not involving underlying fascia and Stage IV involving damage to muscle, bone, or supporting structures. Stage I ulcers are characterized by intact skin with non-blanchable redness over a bony area.