The wound will be documented as: Stage 2.
Stage two pressure injury is the point when the sores experienced go a bit beyond the surface of the skin. The wound is open and may look like a blister filled with pus. It could also be painful.
A see-through dressing and pain relief medications can be used to heal the injury at this stage.
So, the nurse attending to the man in this question should document the injury as stage 2.
Complete Question:
Mr. H. is a 73 year old male who is chairbound. A pressure injury is observed on the right ischial tuberosity. The wound is shallow with a red wound bed. No slough is observed. Tissue loss extends into the dermis. How do you document this?
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