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A nurse is assessing a pressure ulcer on the heel of a 75-year-old male. She notes that the ulcer is deep, extending to the muscle and bone. How would the nurse stage this ulcer?

Explanation

• Stage IV pressure ulcers: Full thickness skin loss, exposed bone, tendon, or muscle, slough or eschar, and tunneling

• Stage I pressure ulcers: Skin intact, red, non-blanching, warm, painful

• Stage II pressure ulcers: Skin is not intact, loss of the dermis occurs, pink/red, open wound, shallow

• Stage III pressure ulcers: Full thickness skin loss, extends into the dermis and subcutaneous tissue. Slough and tunneling may be present

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