A client has a wound on his left trochanter that is 4 inches in diameter, with black tissue at the perimeter, and bone is exposed. Which is the nurse's best action?
a. Document as a stage I pressure ulcer and apply a transparent dressing.
b. Document as a stage II pressure ulcer and start wet-to-dry gauze treatments.
c. Document as a stage III pressure ulcer and start antibiotic therapy.
d. Document as a stage IV pressure ulcer and prepare the client for débridement.
D
A stage IV ulcer is one in which skin loss is full thickness, with extensive destruction, tissue ne-crosis, and/or damage to muscle, bone, or supporting structures. Eschar may be present. When the bone of the trochanter area is visible, tissue loss includes muscle loss. A potential intervention consists of débridement of the necrotic tissue and a possible graft to promote healing.
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