A middle-age adult paraplegic patient has been admitted for follow-up from a traumatic brain injury received while serving in Afghanistan. The admitting diagnosis is failure-to-thrive

Question

On admission, the patient was found to have a wound on the 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

Answer 1

C
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 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 IV: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling