After completing a scheduled every-2-hour turn by turning the client to the left side, the nurse notices a reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure
One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area?
1. Reactive hyperemia
2. Stage I pressure ulcer
3. Stage II pressure ulcer
4. Stage III pressure ulcer
Correct Answer: 1
Rationale: If the reddened area blanches with thumb pressure and disappears in one-half to three-quarters of the time pressure was on the area, the condition is reactive hyperemia and no damage to the skin and tissues has occurred. Stage I pressure ulcers are reddened areas that do not blanch with thumb pressure and that do not clear in the allotted amount of time. Stage II pressure ulcers show partial-thickness skin loss and have the appearance of abrasions, blisters, or shallow craters. Stage III pressure ulcers demonstrate full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
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