The nurse is assessing a client's wound on admission to the healthcare facility. The client has a loss of epidermis with damage into the dermis that appears as a shallow crater/blister with red/pink wound bed and no sloughing on the right hip
Based on this information, what stage pressure ulcer should the nurse document in the electronic medical record? A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
B
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This is stage 2, loss of epidermis with damage into the dermis that appears as a shallow crater/blister with red/pink wound bed and no sloughing. Stage 1 is pressure related alteration of intact skin. In stage 3, subcutaneous tissues are involved and subcutaneous fat may be visible with no bone, tendon, or muscle exposed. Stage 4 is extensive damage to underlying structures, full-thickness tissue loss with exposed bones, tendons, or muscles.
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