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Marcus Lee is a 34-year-old male admitted after a motorcycle accident resulting in a thoracic spinal cord injury (T6). He reports paralysis from the waist down and relies on staff for turning and transfers. Marcus reports decreased sensation in the buttocks and lower extremities.
Over the last 48 hours, Marcus has had multiple episodes of bowel and bladder incontinence due to neurogenic dysfunction. His linens were noted to be damp overnight. Marcus has not been eating well, consuming only 30-40% of meals. His albumin level is low, and he has lost weight over the past month.
During the nurse's skin assessment of the sacral area, the following is observed:
A shallow open area with a pink wound bed
Partial-thickness skin loss involving the epidermis and part of the dermis
No slough visible
Surrounding erythema

Medical history includes:

Newly diagnosed neurogenic bladder and bowel
Paraplegia
MVA

What stage is this pressure injury?

A.

Stage IV

B.

Stage I

C.

Stage II

D.

Stage III

E.

Deep Tissue Pressure Injury (DTPI)

Answer and Explanation

The Correct Answer is C

A. Stage IV: This stage involves full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, or bone. The case description specifies only partial-thickness loss involving the epidermis and dermis. There is no mention of deep tissue exposure in Marcus.

B. Stage I: A stage I pressure injury is characterized by non-blanchable erythema of intact skin. The assessment of Marcus identifies a shallow open area, which indicates a break in skin integrity. Therefore, the injury has progressed beyond the initial stage of redness.

C. Stage II: This stage is defined by partial-thickness loss of the dermis, presenting as a shallow open ulcer with a red-pink wound bed. The absence of slough or bruising is consistent with this classification. Marcus's assessment findings perfectly align with these specific criteria.

D. Stage III: Stage III involves full-thickness skin loss where adipose tissue is visible in the ulcer. The description of Marcus's wound as a shallow open area confirms it has not penetrated the subcutaneous layer. It remains restricted to the upper cutaneous layers.

E. Deep Tissue Pressure Injury (DTPI): This injury presents as a localized area of persistent non-blanchable deep red, maroon, or purple discoloration. Marcus's wound bed is described as pink and open, which contradicts the intact, dark discoloration seen in DTPI. The mechanics of his injury are superficial.


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Related Questions

Correct Answer is D

Explanation

A. Phalanges and clavicle: The phalanges are the distal bones of the digits involved in grasping, while the clavicle anchors the upper limb to the axial skeleton. Neither bone participates in the rotational mechanics of the forearm. Their anatomical positions are too distal and proximal, respectively, to influence radioulnar rotation.

B. Metacarpal and carpal: These bones form the structural framework of the hand and the wrist joint proper. While they move as a unit during forearm rotation, they do not provide the pivot mechanism required for pronation or supination. Their primary movements include flexion, extension, and radial or ulnar deviation.

C. Humerus and scapula: These bones constitute the glenohumeral joint, which allows for circumduction and rotation of the entire upper extremity. While the humerus provides the proximal origin for some forearm muscles, it does not rotate during isolated forearm supination. The scapula serves as a stable base for shoulder mobility.

D. Radius and ulna: The proximal and distal radioulnar joints allow the radius to rotate around the relatively stationary ulna. This specialized articulation enables the palm to turn upward (supination) or downward (pronation). Functional integrity of these two bones is essential for common activities of daily living following a fracture.

Correct Answer is C

Explanation

A. Stage IV: This stage involves full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, or bone. The case description specifies only partial-thickness loss involving the epidermis and dermis. There is no mention of deep tissue exposure in Marcus.

B. Stage I: A stage I pressure injury is characterized by non-blanchable erythema of intact skin. The assessment of Marcus identifies a shallow open area, which indicates a break in skin integrity. Therefore, the injury has progressed beyond the initial stage of redness.

C. Stage II: This stage is defined by partial-thickness loss of the dermis, presenting as a shallow open ulcer with a red-pink wound bed. The absence of slough or bruising is consistent with this classification. Marcus's assessment findings perfectly align with these specific criteria.

D. Stage III: Stage III involves full-thickness skin loss where adipose tissue is visible in the ulcer. The description of Marcus's wound as a shallow open area confirms it has not penetrated the subcutaneous layer. It remains restricted to the upper cutaneous layers.

E. Deep Tissue Pressure Injury (DTPI): This injury presents as a localized area of persistent non-blanchable deep red, maroon, or purple discoloration. Marcus's wound bed is described as pink and open, which contradicts the intact, dark discoloration seen in DTPI. The mechanics of his injury are superficial.

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