A nurse notes a 2-mm open shallow ulcer with a red wound bed on the great toe where shoe touched the skin. Which of the following should the nurse document?
A) 2-mm stage II pressure ulcer
B) Stage III pressure ulcer on great toe
C) 2-mm skin tear with red wound bed
D) Red ulcer on the great toe 2 mm in size
Ans: A
The wound described is a pressure ulcer, and Pressure Ulcer Scale for Healing (PUSH) staging should be used to document all pressure ulcers. Wound documentation should also include size of wound bed. Stage II ulcers are partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.
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