Question

the nurse performs wound care to the clients sacral pressure wound. the wound bed is mainly filled with eschar with a small amount of pink tissue near the borders. the wound measures 5 cm by 8 cm. how should the nurse describe the wound in the clients chart? answers: a - d a stage 2 pressure injury to sacrum measuring 5 cm by 8 cm. b 5 cm by 8 cm unstageable pressure injury to the sacrum. c stage 1 pressure injury to the sacrum that measures 5 cm by 8 cm. d 5 cm by 8 cm stage 3 pressure injury to the sacrum.

Explanation:

When a wound bed is mainly filled with eschar, it is an unstageable pressure injury. Eschar prevents accurate staging of the wound depth.

Answer:

B. 5 cm by 8 cm unstageable pressure injury to the sacrum.