The nurse is admitting a client with a pressure ulcer to the long-term care facility. When assessing the wound, the nurse finds partial-thickness skin loss free of eschar. In which stage is this client's ulcer?
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
2
Rationale 1: A stage I ulcer is characterized by erythema that does not resolve within minutes of pressure relief.
Rationale 2: A stage II ulcer has partial-thickness skin loss free of eschar.
Rationale 3: A full-thickness loss that goes through the dermis to the subcutaneous tissue but does not extend through the underlying fascia is a stage III pressure ulcer.
Rationale 4: Stage IV pressure ulcers have full-thickness skin loss, and can involve muscle, joint, and/or bone. This client has a stage II ulcer.
Global Rationale: A stage I ulcer is characterized by erythema that does not resolve within minutes of pressure relief. A stage II ulcer has partial-thickness skin loss free of eschar. A full-thickness loss that goes through the dermis to the subcutaneous tissue but does not extend through the underlying fascia is a stage III pressure ulcer. Stage IV pressure ulcers have full-thickness skin loss, and can involve muscle, joint, and/or bone. This client has a stage II ulcer.
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