Mrs. Bryant is a 78-year-old patient with diabetes who recently moved into an assisted living apartment because she needs assistance with bathing and housework
When the assistive nursing personnel bathed her for the first time, she noticed that there was a large blister on her right heel. She asked Mrs. Bryant about it, and she denied knowledge of having injured herself. It was re-ported to the nurse who correctly documented it as what stage of a pressure ulcer? A. Stage I
B. Stage II
C. Stage III
D. Stage IV
B
Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence
Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister
Stage 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
Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle
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