When assessing a patient's pressure ulcer, the nurse finds that it is 3 cm in diameter and 1 cm deep and has tunneling on the left side. The ulcer holds 17 mL of normal saline. There is no visible fascia or bone in the ulcer
What pressure ulcer stage should the nurse document?
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4
ANS: C
A stage 3 ulcer has full-thickness skin loss, which extends to the subcutaneous tissue but not fascia. The ulcer looks like a deep crater and may have undermining of adjacent tissue. Skin is still intact in stage 1; stage 2 is shallow; and stage 4 has damage to muscle and bone.
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