Stage IV ulcer is defined by which description?

Stage IV ulcer is defined by which description?

• A. Full thickness skin loss extending into muscle, tendon, or bone
• B. Epidermal involvement only
• C. Partial thickness skin loss with blister
• D. Nonblanchable erythema limited to the superficial skin

Answer: (A)

Stage IV pressure injuries are defined by full-thickness skin loss with exposure of bone, tendon, or muscle. Reaching this depth means the ulcer has gone through all layers of skin and subcutaneous tissue, and deeper structures may be exposed; undermining or tunneling and the presence of slough or eschar can occur. This is why the description matching full-thickness skin loss extending into muscle, tendon, or bone is the correct one. The other options describe progressively shallower injuries: nonblanchable erythema confined to the superficial skin indicates a Stage I injury; partial-thickness skin loss with a blister indicates Stage II; a deeper full-thickness loss without exposure of bone or tendon corresponds to Stage III, which is not as deep as Stage IV.

Stage IV pressure injuries are defined by full-thickness skin loss with exposure of bone, tendon, or muscle. Reaching this depth means the ulcer has gone through all layers of skin and subcutaneous tissue, and deeper structures may be exposed; undermining or tunneling and the presence of slough or eschar can occur. This is why the description matching full-thickness skin loss extending into muscle, tendon, or bone is the correct one. The other options describe progressively shallower injuries: nonblanchable erythema confined to the superficial skin indicates a Stage I injury; partial-thickness skin loss with a blister indicates Stage II; a deeper full-thickness loss without exposure of bone or tendon corresponds to Stage III, which is not as deep as Stage IV.