Question

wound care consult: client has been spending several hours each day in a wheelchair and has now developed a pressure injury on the coccyx. prior to the accident, the client lived alone at home and was independent with all activities of daily living. pre - existing conditions included morbid obesity and hypertension controlled with a beta blocker. current labs significant for low albumin of 2.9 g/dl (29 g/l). the pressure injury is irregularly shaped, approximately 5.7 inches (14.48 cm) in diameter across the coccyx. there is a bright red skin border of intact skin about 1 inch (2.54 cm) wide, leading into an area of approximately 3.6 inches (9.14 cm) diameter where the skin is completely broken down and subcutaneous fat is clearly visible. the area is damp with oozing serous fluid. no undermining or tunneling is noted; no slough or eschar is seen; no foul odor is noted. plan: negative pressure wound treatment system will be applied with dressing changes bi - weekly by wound care team. over a period of a few days, the area of red skin on the clients coccyx has broken down, and a wound consult has been ordered. the nurse reviews the wound consultants progress notes. complete the following sentence by choosing from the list of options. the nurse recognizes that the client has developed a(n) select... stage 2 pressure injury with partial thickness skin loss and exposed dermis stage 4 pressure injury with full thickness skin and tissue loss unstageable pressure injury stage 3 pressure injury with full thickness skin loss

Explanation:

To determine the pressure injury stage, we analyze the description: the skin is broken down, subcutaneous fat is visible, no slough/eschar (so not unstageable), no full - thickness tissue loss to muscle/bone (ruling out stage 4), and partial - thickness loss is stage 2 (ruled out as we have full - thickness with fat visible). Stage 3 involves full - thickness skin loss with subcutaneous fat visible, which matches the client's condition (skin completely broken down, subcutaneous fat clearly visible, no undermining/tunneling, no slough/eschar).

Answer:

stage 3 pressure injury with full thickness skin loss