2 Pressure Injury Staging Concepts Free Online FlashCards

What determines a pressure injury stage?

Stage pressure injuries by the tissue damage that can be seen or directly assessed—not by wound size or how long it has been present.

What should be assessed before assigning a pressure injury stage?

Identify the likely cause and assess the wound and surrounding skin first. Moisture, trauma, vascular disease, and other conditions can cause skin damage that is not a pressure injury.

What defines a Stage 1 pressure injury?

Stage 1 is intact skin with localized, persistent non-blanchable color change. Temperature, firmness, or sensation changes may also be clues.

What wound features define Stage 2?

Stage 2 is partial-thickness skin loss with exposed dermis and a viable, moist, pink or red wound bed. Fat, deeper tissue, slough, and eschar are absent.

What distinguishes Stage 3 from Stage 4?

Stage 3 is full-thickness skin loss with visible adipose tissue, but without exposed fascia, muscle, tendon, ligament, cartilage, or bone.

What indicates a Stage 4 pressure injury?

Stage 4 is full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone.

When is a pressure injury unstageable?

Classify full-thickness skin and tissue loss as unstageable when slough or eschar obscures its extent; removing the covering would reveal Stage 3 or Stage 4 damage.

How should stable heel eschar be managed for staging?

Do not soften or remove stable heel eschar.

What findings suggest a deep tissue pressure injury?

A deep tissue pressure injury may appear as persistent, non-blanchable deep red, maroon, or purple discoloration, or as epidermal separation exposing a dark bed or blood-filled blister. If deeper tissue is visible, classify by that tissue.

How should moisture-associated skin damage be classified?

Do not label moisture-associated skin damage as Stage 2. Assess its cause and clinical appearance because it can resemble a pressure injury.

Should a skin tear caused by adhesive removal be pressure-staged?

A skin tear from adhesive removal is traumatic damage, not a pressure injury. Document its traumatic cause rather than assigning a pressure injury stage.

How is a device-related pressure injury staged?

Stage a device-related pressure injury by its visible tissue damage, as with other pressure injuries; document the device-related cause.