Question

The nurse assesses impaired skin integrity in this patient. How will the nurse document this?

Stage 1
Stage 2
Stage 3
Stage 4

Answer 1

A nurse documents impaired skin integrity by using a staging system from Stage 1 (non-blanchable erythema of intact skin) to Stage 4 (full-thickness skin and tissue loss), based on the severity of the skin injury.

Step-by-step explanation:

When a nurse assesses a patient's skin condition and notices impaired skin integrity, it is vital to document the findings accurately, following a standardized classification to effectively communicate the patient's condition for subsequent care. Skin integrity issues are typically documented using a numerical staging system:

• Stage 1: Non-blanchable erythema of intact skin
• Stage 2: Partial-thickness skin loss with exposed dermis
• Stage 3: Full-thickness skin loss
• Stage 4: Full-thickness skin and tissue loss

The assessment should be based on the severity of the skin impairment, from the initial stage of persistent redness to the most advanced stage where extensive damage involves muscle, bone, or supporting structures. For example, if the nurse notes that only the upper layer of skin is affected without breaking it, they will document it as Stage 1. If the damage goes deeper into the dermis or beyond, the appropriate higher stage is documented.