Pressure Ulcers (Injuries) Stages, Prevention, Assessment | Stage 1, 2, 3, 4 Unstageable NCLEX

Pressure injuries (formerly called pressure ulcers) education on stages, prevention, nursing interventions, and common pressure ulcer sites NCLEX review.

In this video, I will discuss Stage 1, 2, 3, 4 pressure injuries along with unstageable pressure injuries and deep-tissue injuries.

What is a pressure injury?

It is the breakdown of skin integrity due to unrelieved pressure of some type. This can be from a bony area on the body that comes into contact with a hard surface or a medical device of some type causing unrelieved pressure. In addition, pressure injuries can develop due to friction and shear.

What are the most common sites on the body for pressure injuries? (Note: as the nurse always be aware of your patient’s position)
Heels and Ankles
Hips
Sacral
Elbow
Shoulder
Inside of the knee
Occipital (back of head) and Ears

Stages of Pressure Injures (based on National Pressure Injury Staging System)

Stage 1: Skin is completely intact! The area will be very red but it does NOT blanch (hence turn white when pressed on).

Stage 2: Skin is visibly damaged and NOT intact with PARTIAL loss of the dermis. No subq (fatty tissue) will be visible. Wound may be opened with superficial red/pink opened ulcer or may have the formation of an opened or closed blister.

Stage 3: Skin is visibly damaged and NOT intact with FULL loss of the skin tissue. May see the subq (fatty tissue). Wound edges may be “rolled” away (epibole). Bone, tendon and muscle NOT visible.

Stage 4: Skin is visibly damaged with FULL loss of the skin tissue that will expose bone, muscle, tendon, and ligaments.

Unstageable: Slough (yellowish or tan) or eschar (brownish black) is covering a full thickness ulcer. You can’t assess the actual depth of the wound because of the slough or eschar covering the ulcer.

Deep-Tissue Injury: Presents as purplish or blackish areas over skin that is intact. The fatty tissue below is injured. Also, may look like a black blister area. It may feel heavy or spongy.

Nursing Interventions for Pressure Injuries: Prevention, Detection, and Wound Care!

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