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Tuesday 25 May 2021
[New post] [Answer] A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? Incorrect 1 Stage I Incorrect 2 Stage II Incorrect 3 Stage III Correct 4 UnstageableA pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis dermis or both; the ulcer is superficial and may present as an abrasion blister or shallow crater. A stage III pressure ulcer involves full thickness tissue loss with visible subcutaneous fat. Bone tendon and muscle are not exposed.
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