Chris is a 38-year-old paraplegic patient who had a traumatic brain injury while serving in Afghanistan. He has been a patient in a long-term rehabilitation hospital and was recently admit-ted to an acute-care hospital with failure-to-thrive
On admission, he was found to have a wound on his right scapula. The nurse noted full-thickness tissue loss with tunneling, but did not note any bone, tendon or muscle. This was correctly identified as what stage of a pressure ulcer? A. Stage I
B. Stage II
C. Stage III
D. Stage IV
C
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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