The nurse notes a client’s skin is reddened with a small abrasion and

The nurse notes a client’s skin is reddened with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as:

1. Stage I
2. Stage II
3. Stage III
4. Stage IV

ANSWER

ANS: 2
This description is consistent with a stage II pressure ulcer. A stage II pressure ulcer is defined as partial-thickness skin loss involving the epidermis and/or dermis. The ulcer is superficial and pre-sents clinically as an abrasion, blister, or shallow crater. A stage I pressure ulcer is an observable pressure-related alteration of intact skin whose indicators may include changes in one or more of the following: skin temperature, tissue consistency, and/or sensation. A stage III pressure ulcer has full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. A stage IV pressure ulcer has full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.