A client presents with a pressure ulcer that the nurse is documenting

A client presents with a pressure ulcer that the nurse is documenting in the medical record. The nurse notes necrotic tissue on the pressure ulcer, which indicates that:

1. The pressure ulcer is automatically a stage IV
2. The pressure ulcer cannot be staged
3. The client has been abused
4. The pressure ulcer is healing

ANSWER

ANS: 2
Staging systems for pressure ulcers are based on describing the depth of tissue destroyed. Accu-rate staging requires knowledge of the skin layers, and a major drawback of a staging system is that you cannot stage an ulcer covered with necrotic tissue because the necrotic tissue is covering the depth of the ulcer. The necrotic tissue must be debrided or removed to expose the wound base to allow for assessment. The necrotic tissue present on the pressure ulcer doesn’t necessarily indicate that the client has been abused, nor does it indicate that the wound is healing.