A client has a pressure ulcer on the medial malleolus. The client's skin is intact with purple discoloration and a blood-filled blister. When documenting this finding, which terminology is appropriate for the nurse to use?
A) Partial-thickness loss of dermis
B) Non-blanchable erythema
C) Suspected deep tissue injury
D) Full-thickness tissue loss
Answer: C
A suspected deep tissue injury manifests as intact skin with purple discoloration or a blood-filled blister. Non-blanchable erythema refers to a Stage I ulcer. Partial-thickness loss of dermis refers to a Stage II ulcer. Full-thickness tissue loss refers to Stage III, IV, and unstageable ulcers.
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