A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer

Question

Which of these findings are characteristic of a stage II pressure ulcer? Select all that apply.
a.
Intact skin appears red but is not broken.
b.
Partial thickness skin erosion is observed with a loss of epidermis or dermis.
c.
Ulcer extends into the subcutaneous tissue.
d.
Localized redness in light skin will blanch with fingertip pressure.
e.
Open blister areas have a red-pink wound bed.
f.
Patches of eschar cover parts of the wound.

Answer 1

ANS: B, E
Stage I pressure ulcers have intact skin that appears red but is not broken, and localized redness in intact skin will blanche with fingertip pressure. Stage II pressure ulcers have partial thickness skin erosion with a loss of epidermis or also the dermis; open blisters have a red-pink wound bed. Stage III pressure ulcers are full thickness, extending into the subcutaneous tissue; subcutaneous fat may be seen but not muscle, bone, or tendon. Stage IV pressure ulcers involve all skin layers and extend into supporting tissue, exposing muscle, bone, and tendon. Slough (stringy matter attached to the wound bed) or eschar (black or brown necrotic tissue) may be present.