Which statement describes a Stage 4 Ulcer?

Which statement describes a Stage 4 Ulcer?

• A. Full Thickness Loss With Exposed Bone Or Muscle.
• B. Partial Thickness Loss With Exposed Dermis.
• C. Intact Skin With Non-Blanchable Redness Localized Area.
• D. Full Thickness Loss With Exposed Subcutaneous Fat.

Answer: (A)

Staging of pressure injuries is based on how deep the tissue loss goes and what underlying structures are exposed. A Stage 4 ulcer represents the deepest level, with full-thickness tissue loss where the damage extends through the skin to bone or muscle. You may also see undermining or tunneling, and the wound bed can contain slough or eschar. This distinguishes it from other stages: Stage 2 is partial-thickness loss involving only the epidermis and/or dermis with a pink-red wound bed or a blister; Stage 1 is intact skin with non-blanchable redness; Stage 3 is full-thickness loss with visible subcutaneous fat but no exposed bone or muscle. So the statement describing full-thickness loss with exposed bone or muscle best fits Stage 4.

Staging of pressure injuries is based on how deep the tissue loss goes and what underlying structures are exposed. A Stage 4 ulcer represents the deepest level, with full-thickness tissue loss where the damage extends through the skin to bone or muscle. You may also see undermining or tunneling, and the wound bed can contain slough or eschar. This distinguishes it from other stages: Stage 2 is partial-thickness loss involving only the epidermis and/or dermis with a pink-red wound bed or a blister; Stage 1 is intact skin with non-blanchable redness; Stage 3 is full-thickness loss with visible subcutaneous fat but no exposed bone or muscle. So the statement describing full-thickness loss with exposed bone or muscle best fits Stage 4.