The nurse notes that the client's skin is reddened, with a small intact serum-filled blister. How should the nurse classify this stage of ulcer formation?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
B
The description is consistent with a stage II pressure ulcer. A stage II pressure ulcer is defined as partial thickness, loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister.
A stage I pressure ulcer is intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its colour may differ from the surrounding area. The description is not consistent with a stage I pressure ulcer.
A stage III pressure ulcer has full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. It may include undermining tunnelling. The description is not consistent with a stage III pressure ulcer.
A stage IV pressure ulcer has full-thickness tissue loss with exposed bone, tendon, or muscle. Slough eschar may be present on some parts of the wound bed. The description is not consistent with a stage IV pressure ulcer.
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