Staging without second-guessing
Staging describes tissue loss, and the rule is simple: you stage by the deepest layer visible. A stage 1 pressure injury is intact skin with localized non-blanchable erythema; in darker skin tones the change may appear as a difference in colour, temperature, firmness or sensation compared with surrounding tissue rather than redness. If the area blanches when pressed and refills, it is reactive hyperaemia, not a stage 1 injury.
Stage 2 is partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, or as an intact or ruptured serum-filled blister. There is no slough, no granulation tissue and no exposed fat. Stage 3 is full-thickness loss where subcutaneous fat is visible; undermining and tunnelling may be present, and depth varies by location because the bridge of the nose and the ear have little subcutaneous tissue. Stage 4 exposes muscle, tendon, cartilage or bone, and osteomyelitis becomes a concern.
Two categories sit outside the numbered system. An unstageable injury has a base obscured by slough or eschar, so the true depth cannot be determined until the wound is debrided — with the important exception that stable, dry, adherent eschar on an ischaemic heel is left intact as a biological cover. A deep tissue pressure injury shows persistent non-blanchable deep red, maroon or purple discolouration of intact skin, or a blood-filled blister, and can deteriorate rapidly.
| Stage | Skin integrity | Defining feature |
|---|---|---|
| Stage 1 | Intact | Non-blanchable erythema |
| Stage 2 | Partial thickness | Shallow open ulcer or serum-filled blister |
| Stage 3 | Full thickness | Subcutaneous fat visible; may tunnel |
| Stage 4 | Full thickness | Muscle, tendon or bone exposed |
| Unstageable | Full thickness | Base covered by slough or eschar |
| Deep tissue | Intact or blistered | Purple or maroon discolouration |
Risk assessment and the Braden Scale
The Braden Scale scores six subscales — sensory perception, moisture, activity, mobility, nutrition, and friction and shear — for a total between 6 and 23. Lower totals mean higher risk. On the exam, remember that 19 to 23 indicates no risk, 15 to 18 mild risk, 13 to 14 moderate risk, 10 to 12 high risk, and 9 or below severe risk. The assessment is completed on admission, then at regular intervals and whenever the client's condition changes.
A score alone is not the answer; the exam wants the intervention that matches the low subscale. If moisture scores low, the plan emphasizes prompt incontinence care and a moisture-barrier product. If nutrition scores low, a dietitian referral with protein, calorie and vitamin C supplementation is appropriate. If friction and shear score low, the plan uses a lift sheet, a trapeze and limiting head-of-bed elevation to thirty degrees or less.
Highest-risk clients cluster in predictable stems: older adults, those with impaired sensation from spinal cord injury or neuropathy, malnourished and hypoalbuminaemic clients, those with incontinence, immobilized surgical clients and anyone on prolonged bed rest. Recognizing the risk factor is often the point of the question.
- •Assess skin head to toe at least daily, including under devices
- •Reposition every 2 hours in bed, every hour in a chair
- •Use a 30-degree lateral tilt rather than direct side-lying on the trochanter
- •Keep the head of bed at or below 30 degrees when tolerated
- •Float heels off the mattress with a pillow under the calves
- •Use pressure-redistributing surfaces for moderate and high risk
Prevention interventions the exam scores as correct
Repositioning remains the backbone. A turning schedule that is posted and documented, a thirty-degree lateral tilt rather than direct pressure on the trochanter, heels suspended off the bed, and pillows between the knees and ankles are all defensible answers. Chair-bound clients need repositioning every hour and should be taught to shift weight every fifteen minutes if able.
Skin and moisture management follows: cleanse gently with pH-balanced cleanser and warm rather than hot water, pat dry, apply a moisture barrier for incontinence, and use absorbent underpads that wick moisture away. Distractors that appear plausible but are always wrong include massaging reddened bony prominences, which damages capillaries; using donut or ring cushions, which create a circle of ischaemia; and dragging the client up in bed rather than lifting.
Nutrition and hydration close the loop. Adequate protein, calories, vitamin C, zinc and fluid support tissue repair, and albumin and prealbumin are the labs commonly cited in stems. A dietitian consult for a client with poor intake and a low Braden nutrition subscale is a correct answer, not an extra.
Wound care, dressings and documentation
Dressing selection is matched to the wound bed. Transparent films protect stage 1 skin and superficial partial-thickness wounds. Hydrocolloids suit clean stage 2 wounds with light exudate and maintain a moist environment. Hydrogels rehydrate dry wound beds and support autolytic debridement. Foams and alginates absorb moderate to heavy exudate, with alginates favoured for deep or bleeding wounds. Cavities are loosely packed with moistened gauze so granulation is not crushed, and negative pressure therapy is used for selected stage 3 and 4 wounds.
Cleansing uses normal saline with gentle irrigation. Antiseptics such as povidone-iodine and hydrogen peroxide are cytotoxic to granulation tissue and are not routine wound cleansers — an answer choosing them is nearly always the distractor.
Documentation includes location, stage, measurements in centimetres for length, width and depth, undermining or tunnelling with clock positions, wound bed appearance, exudate amount and odour, periwound condition and pain. Signs of infection — increasing pain, purulence, foul odour, expanding erythema, fever and rising white cell count — are reported rather than simply charted. Healing wounds are described by improvement in measurements and tissue quality; a healing stage 4 injury is never reverse-staged into a stage 2.