Pressure Injury Staging for NCLEX

Clinical Findings

• Intact skin with non-blanchable redness over a localized area
• Usually over a bony prominence
• Skin intact — no open wound
• Area may be painful, firm, soft, warmer, or cooler than adjacent tissue
• Dark skin tones: may appear violet, maroon, or blue — not red

Assessment

• Blanchability test: press with finger 3 seconds — does not blanch (whiten)
• Inspect and palpate: compare temperature and texture to surrounding skin
• Earliest visible indicator of pressure injury — act immediately
• Nursing priority: relieve pressure, increase repositioning frequency, apply protective dressing

Clinical Findings

• Partial thickness loss of dermis — shallow open ulcer
• Pink or red wound bed, moist, no slough
• May present as intact or ruptured serum-filled blister
• No slough or bruising in true Stage 2
• Often very painful due to exposed nerve endings

Assessment

• Measure wound size: length × width (and depth if applicable)
• Assess wound bed color, moisture, exudate
• Do not confuse with moisture-associated skin damage (MASD), tape tears, or skin tears — these are not pressure injuries
• Treatment: moisture-retentive dressings (hydrocolloid, foam); relieve pressure; manage moisture

Clinical Findings

• Full thickness tissue loss — subcutaneous fat may be visible
• No bone, tendon, or muscle exposed
• Slough or eschar may be present but does not obscure the depth
• Undermining or tunneling may be present
• Depth varies by anatomical location — areas with significant fat (buttocks) may be very deep; areas with little tissue (nose, ear) may be shallow

Assessment

• Assess depth, undermining, and tunneling with sterile cotton-tipped applicator
• Document wound dimensions: length × width × depth; note tunneling direction and length
• Assess for signs of infection: warmth, induration, odor, purulent exudate
• Treatment: wound care per order (wet-to-moist, negative pressure wound therapy); nutritional optimization

Clinical Findings

• Full thickness tissue loss with exposed or palpable bone, tendon, or muscle
• Slough or eschar may be present on portions of wound bed
• Undermining and tunneling common
• Osteomyelitis risk is significant — bone involvement must be assessed
• May be life-threatening in severe cases

Assessment

• Probe-to-bone test: if a sterile probe contacts bone, osteomyelitis is presumed until proven otherwise
• Assess extent of undermining and tunneling thoroughly
• Monitor for systemic signs of infection: fever, elevated WBC, bacteremia
• Multidisciplinary team required: wound care specialist, dietitian, PT/OT, possibly surgery

Clinical Findings

• Full thickness tissue loss in which actual depth is hidden by slough (yellow, tan, gray, green, brown) or eschar (tan, brown, black)
• True depth cannot be determined until slough/eschar is removed
• Exception: stable, dry, adherent eschar on heels without fluctuance is NOT debrided — it serves as a natural biological cover

Assessment

• Document as unstageable until wound bed can be visualized
• Once debrided, stage becomes apparent — typically Stage 3 or 4
• Assess for signs of infection under eschar: odor, softening of eschar, periwound erythema
• Debridement ordered by provider — do not debride without an order

Clinical Findings

• Persistent non-blanchable deep red, maroon, or purple discoloration — or epidermal separation revealing dark wound bed or blood-filled blister
• Skin intact or nearly intact
• Pain and temperature change (firm/boggy/warmer/cooler) often precede color changes
• Results from intense and/or prolonged pressure and shear forces at the bone-muscle interface

Assessment

• May evolve rapidly — can progress to Stage 3/4 within hours or days despite optimal care
• Assess closely at every shift and document changes carefully
• Immediate pressure relief is essential
• Inform provider and document clearly — DTPI may be a HAPI if it develops during hospitalization