In which of the following stage of pressure ulcer nurse will observe there is partial thickness, loss of dermis with open ulcer with wound without slough?

Appeared in: RUHS, Jaipur, M.Sc Nursing Entrance Exam-2015

Explanation

A Stage II pressure ulcer is characterized by partial-thickness loss of the dermis.
It appears as a shallow, open ulcer with a red-pink wound bed.
A key feature of Stage II is the absence of slough (yellow, tan, gray, green, or brown necrotic tissue).
This stage can also manifest as an intact or ruptured serum-filled blister.

Option A: A Stage I pressure ulcer involves intact skin with non-blanchable redness. There is no skin loss or open ulcer.
Option C: A Stage III pressure ulcer is a full-thickness skin loss where subcutaneous fat is visible. The damage is deeper than just the dermis, and slough may be present.
Option D: A Stage IV pressure ulcer is the most severe, involving full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar is commonly present.

Clinical Relevance

Nursing practice connection: Knowing Pressure Ulcer Staging helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Accurate staging of a pressure ulcer is critical for planning appropriate wound care, selecting the right dressing, and implementing preventive measures.
Incorrect staging can lead to improper treatment, delayed healing, and increased risk of complications like infection.
Staging is also essential for legal and regulatory documentation in healthcare facilities.

How to Approach the Question

First, identify the key descriptive terms in the question: 'partial thickness', 'loss of dermis', 'open ulcer', and 'without slough'.
Next, recall the definitions for each of the four stages of pressure ulcers.
Compare the keywords from the question to the definition of each stage.
Stage I involves intact skin.
Stage II matches the description of partial-thickness loss of the dermis without slough.
Stages III and IV involve full-thickness loss, which is deeper than described. Therefore, select the option corresponding to Stage II.

Concept Tested & Keywords

Concept Tested: Pressure Ulcer Staging
Stem keywords: pressure ulcer, partial thickness, loss of dermis, open ulcer, without slough
Lead-in keywords: In which
Negative lead-in flag: false

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E6 Nursing Fundamentals Taylor pp. 560-562, 581-583

E6 Nursing Fundamentals Potter Perry 12e Part 6 p. 69-71

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