A client has intact skin with persistent non-blanchable deep red and purple discoloration over the sacrum. Click the correct classification.
Hot Spot
Choose your responses, then check the answer.
Explanation
Deep tissue injury is the best answer. Deep tissue pressure injury presents as persistent non-blanchable deep red, maroon, or purple discoloration. Other marked areas do not best match the cue in this item.
Quick answer Deep tissue injury is the best answer. Deep tissue pressure injury presents as persistent non-blanchable deep red, maroon, or purple discoloration. Other marked areas do not best match the cue in this item.
Why this is correct Pressure-injury classification is based on the deepest visible tissue and whether the skin is intact. Color alone does not replace the depth and tissue description supplied in the stem.
Easy analogy or mental picture Picture skin as layers: Stage 2 reaches exposed dermis, Stage 3 extends through full thickness into subcutaneous tissue, and deep-tissue injury may remain intact while showing persistent deep red, maroon, or purple discoloration.
Memory hook Persistent deep red, maroon, or purple discoloration under intact skin points to deep-tissue pressure injury.
NCLEX decision rule When staging a pressure injury, identify skin integrity, depth, and exposed tissue in that order; do not stage beyond what is visible.
Why the other choices are wrong The other images represent different depths or tissue patterns. Choosing by wound size or color without checking depth is the common trap.
References
[1]
NCBI Bookshelf: Pressure injury staging
Clinical situationA client has intact skin with persistent non-blanchable deep red and purple discoloration over the sacrum.
What the nurse should noticeDeep tissue injury is the best answer. Deep tissue pressure injury presents as persistent non-blanchable deep red, maroon, or purple discoloration. Other marked areas do not best match the cue in this item.
Transfer to practiceWhen staging a pressure injury, identify skin integrity, depth, and exposed tissue in that order; do not stage beyond what is visible.
Deep tissue injury — Deep red or purple discoloration.
Non-blanchable discoloration — Color that does not turn pale when pressure is applied.