The nurse is examining a shallow, open ulcer with a red-pink wound bed on a patient's sacrum. The nurse would document this wound in Stage II.
A stage II pressure ulcer is defined as a shallow, open wound with a red-pink wound bed. A pressure ulcer in stage I is an area of intact skin with nonblanchable redness. Stage III is defined as full-thickness tissue loss. Full-thickness tissue loss with exposed bone, tendon, or muscle is stage IV. The sacrum is a shield-shaped bony structure that connects to the pelvis and is located at the base of the lumbar vertebrae. The sacrum is responsible for forming the posterior pelvic wall as well as strengthening and stabilizing the pelvis.
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