NUR 242 Med-Surg Exam 1: Questions & Answers: Latest Updated Guide

Stage 1 pressure ulcer (Ans- - skin is intact - area, usually over a bony prominence, red and does not blanch with external pressure Stage 2 pressure ulcer (Ans- - skin is not intact - there partial -thickness skin loss of the epidermis or dermis - ulcer is superficial and maybe an abrasion, a blister (open or fluidfilled, or a shallow crater) Stage 3 pressure ulcer (Ans- - skin loss is full thickness subcutaneous tissue may be damaged or necrotic - damage extends to fascia, bone, tendon and muscle - undermining and tunneling may or may not be presentStage 4 pressure ulcer (Ans- -Skin loss is full thickness with exposed or palpable muscle, tendon, or bone - often excludes undermining and tunneling - sinus tracts may develop - slough and eschar are often present or at least part of the wound