When a patient has full-thickness loss but the depth is unknown, how should the nurse classify this pressure ulcer?
a. Stage/Category III
b. Unstageable
c. Suspected deep tissue injury
d. Stage/Category IV
B
Unstageable: Full-thickness tissue loss-depth unknown.
Stage/Category III: Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Suspected Deep Tissue Injury—Depth Unknown: Purple or maroon localized area of discolored intact skin or blood-filled blister owing to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared with adjacent tissue.
Stage/Category IV: Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often includes undermining and tunneling.
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