An elderly patient was admitted 1 hour ago from a long term care facility with a stage II pressure ulcer on her sacrum. During the initial assessment of the patient the nurse would expect to find?

Answer 1

During the initial assessment of the elderly patient with a stage II pressure ulcer on the sacrum, the nurse would expect to find partial thickness skin loss involving the epidermis and possibly the dermis, presenting as a shallow open sore. The ulcer may appear pink or red and may have some serous drainage, but it should not exhibit necrotic tissue or full thickness skin loss. Surrounding skin may show signs of irritation or moisture. The nurse should also assess the patient's overall skin condition and any contributing factors, such as mobility status and nutritional needs.