The evening nurse reviews the nursing documentation in the male client’s chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client’s sacral area?
a. Intact skin
b. Full-thickness skin loss
c. Exposed bone, tendon, or muscle
d. Partial-thickness skin loss of the dermis
Answer D.
In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact, open or ruptured, serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage 3. Exposed bone, tendon, or muscle is present in stage 4.
a. Intact skin
b. Full-thickness skin loss
c. Exposed bone, tendon, or muscle
d. Partial-thickness skin loss of the dermis
Answer D.
In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also present as an intact, open or ruptured, serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage 3. Exposed bone, tendon, or muscle is present in stage 4.