A nurse is assessing the sacral pressure ulcer of a 89-year-old female. She notes that the skin is not intact and the wound bed appears pink with serum fluid. How would the nurse stage this ulcer?
• Stage II pressure ulcers: Skin is not intact, loss of the dermis occurs, pink/red, open wound, shallow
• Stage I pressure ulcers: Skin intact, red, non-blanching, warm, painful
• Stage III pressure ulcers: Full thickness skin loss, extends into the dermis and subcutaneous tissue. Slough and tunneling may be present
• Stage IV pressure ulcers: Full thickness skin loss, exposed bone, tendon, or muscle, slough or eschar, and tunneling