During a skin assessment of a client who is immobile, the nurse finds an open area over the sacrum with full-thickness skin loss. Subcutaneous fat is visible, and yellow slough covers part of the wound bed, but the depth of the wound can be seen. No bone, tendon, or muscle is visible or palpable. How should the nurse document this wound?
- AStage 2 pressure injury
- BStage 3 pressure injury
- CStage 4 pressure injury
- DUnstageable pressure injury
Show answer and explanations
Answer
B
A: Visible adipose indicates deeper loss than Stage 2. B: Full-thickness skin loss with visible adipose and no exposed deeper structures fits Stage 3. C: Stage 4 requires exposed or directly palpable deeper structures such as muscle or bone. D: The described base is visible rather than obscured by slough or eschar.
A
Visible adipose indicates deeper loss than Stage 2.
B
Full-thickness skin loss with visible adipose and no exposed deeper structures fits Stage 3.
C
Stage 4 requires exposed or directly palpable deeper structures such as muscle or bone.
D
The described base is visible rather than obscured by slough or eschar.