A nurse is assessing a patient’s wound dressing and observes a watery red drainage. How should the nurse document this type of drainage?

Choice A rationale

Full thickness skin loss with visible bone is not described in the question. This would be a description of a stage IV pressure ulcer, which involves full thickness tissue loss with exposed bone, tendon, or muscle.

Choice B rationale

Intact skin with localized erythema is not described in the question. This would be a description of a stage I pressure ulcer, which involves intact skin with non-blanchable redness of a localized area usually over a bony prominence.

Choice C rationale

Partial-thickness skin loss with red tissue is not described in the question. This would be a description of a stage II pressure ulcer, which involves partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

Choice D rationale

Full thickness skin loss with visible adipose tissue is the condition described in the question. This would be a description of a stage III pressure ulcer, which involves full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.

Choice A rationale

Visual aids can be very helpful for patients with impaired speech. They can use pictures, written words, or devices to help express their thoughts2324.

Choice B rationale

Allowing extra time to communicate with the patient is crucial. It can reduce frustration and improve the effectiveness of communication2324.

Choice C rationale

Completing sentences for the patient can be disrespectful and may not accurately convey the patient’s thoughts2324.

Choice D rationale

Asking open-ended questions can be challenging for a person with impaired speech. It’s better to ask yes/no questions or use other communication strategies2324.