Before We Start
Why pressure injuries happen and why staging matters
A pressure injury (formerly called a "pressure ulcer" or "bedsore") develops when sustained pressure — usually over a bony prominence like the sacrum, heels, hips, or elbows — compresses blood vessels enough to cut off local blood flow. Without oxygen and nutrients, the tissue begins to die, starting at the skin surface (in most cases) and potentially progressing deep into muscle and bone if pressure isn't relieved.
Staging exists to communicate severity in a standardized way across the entire care team — a Stage II documented by one nurse should mean the same thing to the nurse on the next shift, the wound care specialist, and the surgeon. But staging only describes what has already happened. The nursing priority is always prevention — because a Stage IV pressure injury can take months to heal and carries serious infection risk, while Stage I is often fully reversible within days if pressure is relieved.
💡 The Braden Scale
The Braden Scale is the standardized tool used to assess a patient's risk for developing a pressure injury, scoring six categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Lower scores mean higher risk. A patient with a low Braden score should trigger more frequent turning, a pressure-relieving surface, and closer skin assessment — risk assessment drives the intensity of prevention, not a one-size-fits-all schedule.
Staging
Pressure injury stages — what each looks like and means
Stage I
Non-blanchable redness — intact skin
Skin is intact but shows localized redness that does not blanch (turn white) when pressed — this is the key distinguishing feature from normal, reactive redness, which does blanch. The area may also feel firmer, softer, warmer, or cooler than surrounding tissue.
Intervention: Relieve pressure immediately (reposition off the area), keep the skin clean and moisturized, and increase turning frequency. Stage I is fully reversible if pressure is relieved promptly — this is the critical window where nursing action prevents progression.
Stage II
Partial thickness skin loss — shallow open ulcer or blister
The epidermis and part of the dermis are lost, presenting as a shallow open ulcer with a pink or red wound bed, or as an intact or ruptured blister. No subcutaneous tissue, fat, muscle, or bone is visible, and there is no slough (yellow, stringy dead tissue) or eschar (black/brown dead tissue) present.
Intervention: Keep the wound bed moist (not wet) to promote healing, protect from further friction and shear, and continue pressure relief and repositioning.
Stage III
Full thickness skin loss — subcutaneous tissue visible, no bone/tendon
The wound extends through the full thickness of the skin into the subcutaneous (fat) tissue. Fat may be visible, but bone, tendon, and muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. Undermining and tunneling (wound extending under the skin edges) may be present.
Intervention: Requires specialized wound care (debridement of nonviable tissue as needed, appropriate dressings), infection monitoring, and often referral to a wound care specialist, in addition to continued pressure relief.
Stage IV
Full thickness tissue loss with bone, tendon, or muscle exposed
The most severe stage — bone, tendon, or muscle is directly visible or palpable in the wound bed. Slough and/or eschar may be present. Undermining and tunneling are common. These wounds carry high risk of osteomyelitis (bone infection) and sepsis, and typically require surgical intervention alongside intensive wound care.
Unstageable
Covered by slough or eschar — depth cannot be determined
The wound bed is obscured by slough (yellow) or eschar (black/brown, leathery), so the true depth cannot be assessed — it cannot be staged until enough of the dead tissue is removed (debrided) to visualize the wound bed. It may turn out to be Stage III or Stage IV once debrided.
Important exception: Stable (dry, adherent, intact, without erythema or fluctuance) eschar on an ischemic limb or the heel should NOT be removed — it acts as "the body's natural cover" and removing it can introduce infection into tissue that has poor blood supply to heal.
Deep Tissue Injury (DTI)
Purple/maroon discoloration with intact skin — damage already happened beneath the surface
The skin is intact but shows a localized area of persistent, non-blanchable deep red, maroon, or purple discoloration, or a blood-filled blister. This represents damage to underlying soft tissue from pressure and/or shear — the surface may look deceptively mild while significant tissue damage has already occurred underneath. DTIs can evolve rapidly, sometimes progressing to expose the extent of tissue damage within days despite appropriate care — this doesn't necessarily mean care was inadequate.
Prevention
The interventions that actually prevent pressure injuries
Core Prevention Bundle
Turn, offload, moisturize, feed, assess
Turn every 2 hours — the single most important intervention; redistributes pressure before ischemia sets in. Higher-risk patients (per Braden score) may need more frequent repositioning.
Pressure-relieving surfaces: Specialty mattresses or overlays reduce sustained pressure between turns, especially valuable for patients who cannot be repositioned frequently.
Keep skin dry: Moisture from incontinence, sweat, or wound drainage softens skin and increases breakdown risk — prompt cleansing and moisture barrier products are essential, especially for incontinent patients.
Adequate nutrition: Protein, vitamin C, and zinc all support skin integrity and wound healing — malnourished patients are at significantly higher risk, and nutrition consults are appropriate for high-risk or existing-wound patients.
Never massage over bony prominences — once thought to improve circulation, this is now known to increase tissue breakdown by causing additional mechanical trauma to already-compromised tissue.
💊 "Turn q2h isn't a suggestion — it's the single intervention most directly tied to preventing a Stage I from ever becoming a Stage IV."
🏥 Clinical Scenario — Staging and Escalating Care
An 82-year-old patient with limited mobility following a hip fracture has been on bedrest for 5 days. During your shift assessment, you find changes on the sacrum.
Finding
A 3cm area of red, intact skin over the sacrum that does not blanch when you press it with a gloved finger. Stage I pressure injury. This is reversible right now. Priority: reposition off the area immediately, document the finding, increase turning frequency, notify the care team, and reassess the patient's Braden score to guide the prevention plan.
3 Days Later, Despite Care
The same area now shows a shallow open wound with a pink wound bed, approximately 2cm, no slough present. Progressed to Stage II. Priority: maintain a moist (not wet) wound environment with an appropriate dressing, continue aggressive pressure relief, consider a wound care consult, and reinforce nutrition support.
Separate Patient
A different patient's heel shows intact skin with a dark maroon, non-blanchable discoloration — no open wound is visible. Deep tissue injury (DTI). Even though the skin is intact, this represents damage already occurring beneath the surface. Priority: completely offload the heel (heel-suspension device, not just a pillow that can compress), document thoroughly with photos per policy, and monitor closely — DTIs can evolve rapidly over the following days.
📌 NCLEX Application
Pressure injury questions test staging accuracy and prevention priorities:
Staging distinction: "A wound shows exposed muscle and tunneling. How should the nurse stage this injury?" → Stage IV — bone, tendon, or muscle is visible/palpable.
Prevention priority: "What is the single most important intervention to prevent pressure injury development in an immobile patient?" → Repositioning/turning at least every 2 hours.
Unstageable recognition: "A wound is covered in thick, black, leathery tissue. How is this staged?" → Unstageable — the depth cannot be determined until the eschar is debrided (with the exception of stable eschar on an ischemic limb, which should not be removed).
What NOT to do: "Which action should the nurse avoid when caring for a patient at risk for pressure injuries?" → Massaging reddened areas over bony prominences — this increases tissue trauma rather than improving circulation.
⚠️ The Trap — Confusing Blanchable and Non-Blanchable Redness
Students frequently miss the distinction between normal reactive hyperemia (redness that appears after pressure is relieved, which blanches white when pressed and fades within about an hour) and a true Stage I pressure injury (redness that does NOT blanch — meaning the capillaries are already damaged and cannot be compressed by external pressure). Treating every red spot the same way — either dismissing it or over-escalating it — leads to missed early intervention or wasted resources.
The safeguard: Always perform the blanch test: press firmly on the reddened area for a few seconds and release. If the area turns white and then refills with color (blanches), it's likely reactive hyperemia — reposition and recheck. If the area stays red or discolored despite pressure (non-blanchable), it's a Stage I pressure injury requiring immediate intervention and documentation.
✓ Quick Self-Test
Answer before checking:
1. What is the defining feature that separates Stage I from normal reddened skin?
2. What distinguishes Stage III from Stage IV?
3. Why can't a wound covered in eschar be staged, and when should that eschar NOT be removed?
4. What is a deep tissue injury, and why can it be deceptive?
5. What is the single most important prevention intervention, and why should you never massage a reddened bony prominence?
Answers:
1. Non-blanchable redness — it does not turn white and refill with color when pressed, unlike normal reactive redness.
2. Stage III has subcutaneous (fat) tissue visible but no bone/tendon/muscle exposed; Stage IV has bone, tendon, or muscle directly visible or palpable.
3. Because slough or eschar obscures the wound bed, so the true depth is unknown until debrided. Stable, dry eschar on an ischemic limb or heel should not be removed, since it protects tissue that has poor blood supply to heal.
4. A DTI is intact skin with purple/maroon discoloration or a blood-filled blister — it's deceptive because the surface can look mild while significant tissue damage has already occurred underneath, and it can evolve rapidly.
5. Turning/repositioning at least every 2 hours. Massage was once thought to improve circulation but is now known to cause additional mechanical trauma to already-compromised tissue, worsening breakdown.