Staging pressure injuries

Stage by the deepest tissue visible; pressure injuries are not reverse-staged as they heal.

Deeper tissueStage 1Intact skin, nonblanchable rednessStage 2Partial thickness; exposed dermis or blisterStage 3Full thickness; fat visible; no bone or tendonStage 4Exposed bone, tendon, muscle, or cartilageUnstageableBase covered by slough or escharDeep tissuePersistent maroon or purple area
Pressure injury stages (NPIAP classification). Medical devices such as tubes and masks can also cause pressure injuries.

Risk assessment

The Braden scale has six subscales.

Braden subscaleWhat it measures
Sensory perceptionAbility to feel and respond to discomfort
MoistureExposure of skin to moisture (sweat, urine, stool)
ActivityDegree of physical activity
MobilityAbility to change and control body position
NutritionUsual food intake pattern
Friction and shearSliding and dragging during movement

Scores range from 6 to 23; lower scores indicate higher risk. Assess on admission and per policy.

Pressure injury riskPressureImmobility,sedation, paralysisShear, frictionSliding in bed,draggingMoistureIncontinence, sweatHostMalnutrition, poorperfusion, age
Risk factors. Bony prominences such as the sacrum, heels, hips, and back of the head are most affected.

Prevention and treatment

Prevention is far easier than healing.

InspectSkin everyshiftRepositionSchedule;lift, do notdragOffloadHeels up;supportsurfacesMoistureClean, dry,barrier creamNutritionProtein,calories,fluids
Prevention. Use lift sheets to move clients; keep head of bed at 30° or less when not contraindicated.
  • Do not massage reddened areas or use donut-shaped cushions.
  • Use the 30° lateral tilt rather than lying directly on the hip.
  • Wound care is guided by stage and wound bed: keep the bed moist and surrounding skin dry; debridement and dressings per order and wound team.
  • Report signs of infection: increasing pain, redness, warmth, purulent drainage, odor, fever.

Other complications of immobility

Immobility affects every body system.

SystemComplicationPrevention
RespiratoryAtelectasis, pneumoniaTurn, cough, deep breathe; incentive spirometry
CardiovascularDVT, orthostatic hypotensionLeg exercises, compression devices, gradual position changes
MusculoskeletalContractures, muscle and bone lossRange of motion, positioning, early mobility
GIConstipationFluids, fiber, mobility, bowel regimen
UrinaryStasis, infection, stonesFluids, avoid unnecessary catheters
PsychosocialIsolation, depression, disorientationInteraction, routine, orientation

Early, progressive mobility is one of the strongest preventive measures.

NGN-style case

Staging and first actions.

functions Clinical judgment case — the sacral wound

A client with dementia and incontinence has a sacral wound: a shallow open area with a pink wound bed and no slough. The surrounding skin is moist. Braden score is 12. What stage is the wound, and what should the nurse do?

  1. Recognize cues: partial-thickness loss with a pink bed, no slough or fat visible.
  2. Analyze: stage 2 pressure injury; Braden 12 means high risk.
  3. Act: relieve pressure on the sacrum with a turning schedule and support surface; manage incontinence and protect the skin.
  4. Assess nutrition, document size and appearance, and notify the provider and wound team per policy.

Answer. Stage 2 pressure injury. Offload the area, manage moisture, support nutrition, and document and report.