Pressure Injury Staging and Prevention
What it is
A pressure injury is localized damage to the skin and underlying tissue, usually over a bony prominence or under a medical device, caused by intense or prolonged pressure, often combined with shear. Pressure compresses capillaries, and the resulting ischemia often begins in deep tissue next to bone before the skin shows it. Prevention rests on relieving pressure, reducing friction, shear and moisture, and supporting nutrition; staging names the deepest tissue visible and guides treatment.
What the NCLEX focuses on
- Stage 1: intact skin with non-blanchable erythema; in darker skin, look for color change, warmth, edema or firmness.
- Stage 2: partial-thickness loss with a pink or red moist wound bed, or an intact or ruptured serum-filled blister; no slough and no visible fat.
- Stage 3: full-thickness loss with visible subcutaneous fat; slough, undermining or tunneling can be present, but no bone, tendon or muscle.
- Stage 4: full-thickness loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone.
- Unstageable: slough or eschar hides the wound base; stable, dry eschar on the heels is left in place. Deep tissue injury: intact or non-intact skin with persistent non-blanchable deep red, maroon or purple discoloration.
- Staging is never reversed: a healing stage 4 is documented as a healing stage 4.
- Braden Scale: the lower the score, the higher the risk.
Priority nursing actions
- Score risk with the Braden Scale on admission and per policy, and inspect the skin, including under devices.
- Reposition on an individualized schedule, at least every 2 hours in bed, using a 30-degree lateral tilt.
- Use a pressure-redistribution mattress, float the heels, and move the client with a lift sheet to prevent shear.
- Cleanse promptly after incontinence and apply a moisture-barrier product.
- Refer to the dietitian and support protein, calorie and fluid intake.
- Measure existing wounds: length head to toe, width side to side, depth, and undermining by clock position.
Numbers to know
| Value | Target or rule | Why it matters |
|---|---|---|
| Braden Scale total | 6 to 23; 18 or lower means at risk | Lower scores mean higher risk |
| Repositioning in bed | At least every 2 hours, individualized | Relieves capillary compression |
| Sitting in a chair | Shift weight every 15 minutes; reposition at least every hour | Seated pressure on the ischium is high |
| Head of bed | 30 degrees or lower unless contraindicated | Higher elevation increases sacral shear |
| Side-lying | 30-degree lateral tilt | Avoids direct pressure on the trochanter |
| Protein for clients with pressure injuries | 1.25 to 1.5 g/kg/day | Supports tissue repair |
Common exam traps
- Choosing to massage reddened bony prominences: wrong because massage damages fragile deeper tissue.
- Choosing a donut-shaped ring cushion: wrong because it concentrates pressure on the surrounding tissue and reduces blood flow.
- Choosing to restage a granulating stage 4 as stage 2: wrong because reverse staging is never used.
- Choosing "just a bruise" or stage 1 for a purple area of intact skin: wrong because it is a deep tissue injury.
- Choosing a higher Braden score as higher risk: wrong because lower scores indicate greater risk.
What to teach
- Change position at least every 2 hours in bed and shift weight every 15 minutes in a chair; place a pillow under the calves to float the heels.
- Inspect the skin daily, especially the sacrum, heels and hips, and report redness that does not fade.
- Keep the skin clean and dry, use a barrier cream after incontinence, and lift rather than drag the person in bed.
- Eat enough protein, calories and fluid to support skin healing.
Client handout: Preventing Pressure Injuries (Bedsores) at Home (nurse guide and printable patient handout).
Try 2 NCLEX-style questions on this topic
From the NCLEXPace question bank. Pick your answers, then check them inside NCLEXPace.
The wound care nurse assesses four pressure injuries during rounds. For each wound described, indicate whether it can be given a numeric stage or is unstageable.
For each pressure injury, identify whether it can be given a numeric stage or is unstageable.
| Can be numerically staged | Unstageable | |
|---|---|---|
| Sacral wound with visible subcutaneous fat and a 10 percent rim of yellow slough | ||
| Heel wound whose entire base is covered by soft, moist yellow slough | ||
| Ischial wound with tendon visible at the base | ||
| Trochanter wound covered by thick, adherent black eschar |
A client is assessed as high risk for pressure injury development and is unable to reposition independently. Which action is most appropriate for preventing pressure injury development?
Select the best answer.
- A. Reposition the client every 8 hours and document skin condition after each turn while maintaining the same standard hospital mattress
- B. Maintain the head of the bed above 60 degrees throughout the day to reduce pressure on the heels and improve respiratory comfort
- C. Reposition the client on an individualized schedule with skin reassessment and an appropriate pressure-redistributing support surface
- D. Massage reddened bony prominences during each repositioning to stimulate local circulation and restore normal skin color
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- Potter PA, Perry AG, Stockert PA, Hall AM. Fundamentals of Nursing. 10th ed. Elsevier; 2021.
- Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016;43(6):585-597.
- European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Haesler E, ed. EPUAP/NPIAP/PPPIA; 2019.
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