A nurse is assessing the sacral pressure ulcer of a 89-year-old patient. The nurse notes that the skin is not intact and the wound bed appears pink with serum fluid. How would the nurse stage this ulcer?

II

Explanation

• 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

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