A nurse is assessing a pressure ulcer on the heel of a 75-year-old patient. The nurse 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.