Pressure Injury

Question 1

Stage 1 pressure injury

Answer 1

Intact skin w localized area of non-blanchable erythema

Epidermis remains intact

Assess for differences in color, consistency, temp to surrounding skin

Question 2

Stage 2 pressure injury

Answer 2

Partial thickness skin loss w exposed dermis

Can be intact /blister
Adipose not visible
Does not have slough/ eschar
Tissue loss extends to dermis

Question 3

Stage 3 pressure injury

Answer 3

Full thickness skin loss
Adipose visible
Granulation tissue and epibole often present
Slough/ Eschar possible
Depth varies
Undermining/tunneling possible
Can be classified as unstageable

Question 4

Stage 4 pressure injury

Answer 4

Full thickness skin and tissue loss

Exposed/ directly palpable fascia, muscle, tendon, ligament, bone, cartilage

Epibole, undermining, tunneling often present

Can be classified as unstageable

Assess for osteomyelitis if bone is visible