Asked by Brianna Edwards on Jul 05, 2024

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The patient has a nonblanchable area of redness on the right malleolus.Which pressure injury stage will be recorded in the patient's chart?

A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4

Nonblanchable

Describing skin redness that does not turn white (blanch) when pressed, often indicating pressure injury.

Right Malleolus

The bony protrusion on the outside of the right ankle, part of the fibula bone.

  • Accurately recognize and record the phases of pressure wounds.
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TS
tannu sidhuJul 10, 2024
Final Answer :
A
Explanation :
Stage 1: Intact skin with nonblanchable redness of a localized area,usually over a bony prominence
Stage 2: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed,without slough; may also present as an intact or open/ruptured serum-filled blister
Stage 3: Full-thickness tissue loss; subcutaneous fat may be visible,but bone,tendon,or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling
Stage 4: Full-thickness tissue loss with exposed bone,tendon,or muscle; slough or eschar may be present; often includes undermining and tunneling