Asked by Alexus Seigler on May 24, 2024

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A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? (Select all that apply.)

A) Intact skin appears red but is not broken.
B) Patches of eschar cover parts of the wound.
C) Ulcer extends into the subcutaneous tissue.
D) Open blister areas have a red-pink wound bed.
E) Localized redness in light skin will blanch with fingertip pressure.
F) Partial thickness skin erosion is observed with a loss of epidermis or dermis.

Pressure Ulcer

Localized damage to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear.

Eschar

A dry, dark scab or falling away of dead skin, typically resulting from a burn or wound.

Subcutaneous Tissue

The layer of tissue lying just below the dermis of the skin, containing fat and connective tissues that insulate and protect the body.

  • Recognize the stages and characteristics of pressure ulcers.
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MR
Maria RomuloMay 29, 2024
Final Answer :
D, F
Explanation :
Stage II pressure ulcers have partial thickness skin erosion with a loss of epidermis or also the dermis; open blisters have a red-pink wound bed. Stage I pressure ulcers have intact skin that appears red but is not broken, and localized redness in intact skin will blanche with fingertip pressure. Stage III pressure ulcers are full thickness, extending into the subcutaneous tissue; subcutaneous fat may be seen but not muscle, bone, or tendon. Stage IV pressure ulcers involve all skin layers and extend into supporting tissue, exposing muscle, bone, and tendon. Slough (stringy matter attached to the wound bed) or eschar (black or brown necrotic tissue) may be present. Intact skin that appears red but is not broken and localized redness that blanches with fingertip pressure in light skinned people both describe a Stage I pressure ulcer. Patches of eschar covering parts of the wound describe a Stage IV wound. An ulcer that extends into the subcutaneous tissue is a Stage III pressure ulcer.