Frank is a 4-year-old paraplegic patient with cerebral palsy who was admitted to the hospital with complications from the H1N1 virus. The nurse who was admitting him noted that he had an area of redness on his right malleolus that was nonblanchable
The nurse correctly identified this area as what stage of a pressure ulcer? A. Stage I
B. Stage II
C. Stage III
D. Stage IV
A
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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