A patient is found to have a broken skin on his coccyx that has black eschar covering the base of the wound. How is this wound staged?

A. Allowing the patient to ambulate independently: This intervention is not appropriate for a patient who scores 30 points on the Morse Fall Scale, which indicates a high risk of falling. The patient should be monitored closely and assisted with ambulation to prevent falls.

B. Administering a sedative to keep the patient calm: While it may be important to keep the patient calm, using sedatives should be approached with caution, as they can increase the risk of falls and impair judgment and coordination. This intervention is not the most appropriate approach to fall prevention.

C. Placing the patient in restraints: Restraints should be used only as a last resort and only when necessary to prevent harm to the patient or others. Using restraints can lead to physical and psychological harm and should not be the primary intervention for fall prevention.

D. Implementing a fall prevention protocol: This is the most appropriate intervention for a patient with a high risk of falling. A fall prevention protocol may include measures such as ensuring a clear path, using assistive devices, and conducting regular assessments of the patient's mobility and safety.

E. Educating the patient on using the call light system: This intervention is important for ensuring the patient feels safe and can call for assistance when needed. Educating the patient on the call light system promotes communication and can help prevent falls by encouraging the patient to seek help when they need to move or ambulate.

A. Stage 2: A Stage 2 pressure ulcer is characterized by partial-thickness skin loss, which may present as an open wound or blister. The presence of black eschar indicates that the skin loss is deeper than what is described in Stage 2.

B. Stage 3: A Stage 3 pressure ulcer involves full-thickness skin loss, which may extend into the subcutaneous tissue but does not involve bone or muscle. However, the presence of black eschar suggests that the wound cannot be accurately assessed because the base is not visible.

C. Stage 1: A Stage 1 pressure ulcer is identified by intact skin with non-blanchable redness. Since there is a broken skin and black eschar in this case, it cannot be classified as Stage 1.

D. Unstageable: A wound is considered unstageable when there is full-thickness skin loss and the base of the wound is covered with necrotic tissue (eschar) or slough, making it impossible to determine the depth and true stage of the ulcer. In this scenario, the black eschar covering the base of the wound prevents accurate staging, so the wound is classified as unstageable.