The nurse is caring for a client with a wound that presents with full-thickness tissue loss and eschar covering the wound bed. The nurse would record this wound as which stage?

  • Stage I
  • Stage II
  • Stage III
  • Stage IV
  • unstageable
Number 5 is correct.
Unstageable wounds cannot be staged due to eschar or slough covering the wound. The wound bed must be visualized in order to stage the wound. Stage I ulcers have intact skin with a red area. The area may be firm, painful, soft, or cooler or warmer compared to adjacent tissue. Stage II ulcers present with partial thickness loss of dermis and a red-pink wound bed. No slough is present. Stage III ulcers have full-thickness skin loss and may contain slough. The wound may have visible subcutaneous tissue, and tunneling and undermining may or may not be present. Stage IV ulcers present with full-thickness skin loss and exposed bone, muscle, or tendons. Eschar and slough may be present, and tunneling and undermining may develop.