🛏️ Basic Care & Comfort · Lesson 5 of 6 · 6 min

Pressure Injuries: Stage It, Turn Them, Feed Them

🩹 A reddened area over the sacrum that does not blanch when you press it is already a stage 1 pressure injury. By the time anyone sees bone, the staging question on the exam is the easy part.

💡 Key idea

Stage 1 non-blanchable redness, 2 partial thickness, 3 fat visible, 4 bone or tendon visible, unstageable when covered. Lower Braden means higher risk; turn every 2 hours and protect heels.

🧠 Why it matters

STAGE 1: intact skin with NON-BLANCHABLE redness; in darker skin, look for color change, warmth, firmness or pain. STAGE 2: partial-thickness loss with a shallow open wound or an intact or ruptured blister, pink and moist, no slough. STAGE 3: full-thickness loss with visible fat, possibly undermining; no bone or tendon visible. STAGE 4: full-thickness loss with exposed bone, tendon or muscle. UNSTAGEABLE: the base is covered by slough or eschar so depth cannot be seen. DEEP TISSUE injury: intact or non-intact skin with persistent purple or maroon discoloration. Assess risk with the BRADEN scale (sensory perception, moisture, activity, mobility, nutrition, friction and shear); lower scores mean higher risk, with 18 or below considered at risk. Prevent with repositioning at least every 2 hours, pressure-redistribution surfaces, a 30-degree lateral tilt, heels floated off the bed, the head of the bed no higher than needed to limit shear, moisture management, and adequate protein and calories. Do not massage reddened areas and do not use donut-shaped cushions.

🏥 In the real world

🦶 An immobile client has a 2 cm area of purple, intact, boggy skin on the heel. A new nurse charts 'stage 1'. The experienced nurse corrects it to deep tissue pressure injury, floats the heels on a pillow, and arranges a dietitian consult for the client's low albumin. Purple is not red, and staging decides the wound plan.

📌 Takeaways

Non-blanchable redness is already stage 1
Unstageable means covered by slough or eschar; deep tissue injury is purple or maroon
Braden 18 or below: at risk; turn q2h, float heels, protect from moisture and shear

✅ Test yourself

A pressure injury on the coccyx shows full-thickness tissue loss with visible subcutaneous fat but no exposed bone or tendon. Which stage is this?

Stage 2
Stage 4
Stage 3
Stage 1

Answer: C · Stage 3

Visible fat without bone, tendon or muscle defines stage 3. Stage 4 exposes bone or tendon.

A client's Braden scale score is 12. How should the nurse interpret this?

Low risk; routine care is sufficient
High risk; start a prevention plan
The score is invalid and must be repeated
Only nutrition needs attention

Answer: B · High risk; start a prevention plan

Lower Braden scores mean higher risk; 12 or below is considered high risk.

Which intervention is appropriate for a client at risk of pressure injuries?

Massage reddened bony areas to improve circulation
Reposition every 2 hours and float the heels
Use a donut cushion to relieve pressure when sitting
Keep the head of the bed at 60 degrees at all times

Answer: B · Reposition every 2 hours and float the heels

Repositioning and heel elevation relieve pressure. Massage damages fragile tissue, donuts create pressure rings, and a high head of bed increases shear.

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