A nurse is assessing a 65-year-old patient who has been immobile in a wheelchair for 4 weeks due to spinal cord injury. Which assessment finding would be most indicative of a Stage 3 pressure injury?
1Intact skin with non-blanchable redness and warmth to touch
2Partial-thickness skin loss with exposed dermis and pink wound bed
3Full-thickness skin loss with visible subcutaneous fat and possible slough✓ 정답
4Full-thickness skin and tissue loss with exposed bone and tendon
해설
Stage 3 pressure injuries involve full-thickness skin loss with visible subcutaneous fat and possible slough, but no exposed bone or tendon. Other options describe different stages or characteristics of pressure injuries.
Core Nursing ExplanationKey Concept Analysis: This question tests your knowledge of the National Pressure Injury Advisory Panel (NPIAP) staging system for pressure injuries. The core is understanding the specific tissue layers involved in each stage. A Stage 3 pressure injury is defined as full-thickness loss of skin, where the damage extends through the epidermis and dermis and into the subcutaneous fat layer. The wound bed may contain slough (yellow, stringy dead tissue) or eschar (black, hard necrotic tissue), but bone, tendon, or muscle are not visible.
Answer Rationale: Key Point! The correct answer is option ③ because it accurately describes the hallmark of a Stage 3 injury: "Full-thickness skin loss with visible subcutaneous fat and possible slough." The mention of "visible subcutaneous fat" is the critical differentiator from a Stage 2 (partial-thickness) or Stage 4 (full-thickness with exposed deeper structures) injury.
Distractor Analysis:
Watch out for confusion! Option ① describes a Stage 1 pressure injury: intact skin with non-blanchable erythema (redness). The skin is not broken.
Option ② describes a Stage 2 pressure injury: partial-thickness loss of skin involving the epidermis and/or dermis. It presents as a shallow open ulcer or a ruptured blister with a red-pink wound bed. Subcutaneous fat is not visible.
Option ④ describes a Stage 4 pressure injury: the most severe stage, involving full-thickness skin and tissue loss with exposed or directly palpable bone, tendon, or muscle. The presence of "exposed bone and tendon" is the defining feature that distinguishes it from Stage 3.
Related Concepts: It is crucial to remember that pressure injuries can also be classified as Unstageable (when the wound base is covered by slough or eschar, so the true depth cannot be determined) or Deep Tissue Pressure Injury (DTPI) (intact or non-intact skin with persistent non-blanchable deep red, maroon, or purple discoloration, indicating damage to underlying soft tissue). The patient's immobility and use of a wheelchair are classic risk factors for developing pressure injuries over bony prominences like the sacrum or ischial tuberosities.
Concept Summary
Stage
Key Characteristics
Tissue Layers Involved
Stage 1
Intact skin, non-blanchable redness
Epidermis/Dermis (no open wound)
Stage 2
Partial-thickness loss, shallow open ulcer, pink wound bed
Epidermis and/or Dermis
Stage 3
Full-thickness loss, subcutaneous fat visible, slough/eschar may be present
Full skin thickness into Subcutaneous Fat
Stage 4
Full-thickness loss with exposed/palpable bone, tendon, or muscle
Extends into Muscle, Bone, or supporting structures
Side-by-Side Comparison!
Assessment Feature
Stage 3 Pressure Injury
Stage 4 Pressure Injury
Depth
Extends into subcutaneous fat
Extends into muscle, bone, or tendon
Visible Structures
Fat may be visible, but bone/tendon/muscle are NOT exposed or directly palpable.
Bone, tendon, or muscle is exposed or directly palpable.
Wound Bed
May have slough (yellow) or eschar (black). Granulation tissue and epibole (rolled edges) may be present.
Often has slough or eschar. Undermining and tunneling are common.
Anatomy, Physiology & Pharmacology Points
Anatomy: The skin layers, from superficial to deep, are: Epidermis → Dermis → Subcutaneous Tissue (Hypodermis/Fat) → Fascia → Muscle → Bone. Staging is based on the deepest layer of visible tissue loss.
Pathophysiology: Pressure injuries develop due to unrelieved pressure that occludes capillaries, leading to tissue ischemia, necrosis, and ulceration. Shear and friction are contributing factors.
Pharmacology: While not a direct treatment for staging, wound care often involves topical agents like hydrocolloid dressings (for Stage 2), calcium alginate or foam dressings (for exudating wounds), and enzymatic debriding agents (e.g., collagenase) for slough/eschar.
Memory Tips
Mnemonic for Stages 1-4: "Red but intact (Stage 1), Open and shallow (Stage 2), Fat shows through (Stage 3), Bone on view (Stage 4)." (ROFB)
Think: Stage 3 = "Fat Layer". If you can see the yellow, globular fat tissue, it's Stage 3. If you see something white, shiny, and cord-like (tendon) or hard (bone), it's Stage 4.
High-Frequency NCLEX Topics
Pressure injury staging and prevention are Core NCLEX topics. You will be tested on:
1. Identifying the stage from a description or image.
2. Selecting appropriate nursing interventions for each stage (e.g., turning schedule, support surfaces, wound care).
3. Understanding risk assessment tools like the Braden Scale.
4. Prioritizing care for a patient at risk for or with a pressure injury.
Watch Out for Question Variations!
Shift from "Identify Stage" to "Select Priority Intervention": "The nurse identifies a Stage 3 pressure injury on a patient's sacrum. Which action should the nurse take first?" (Answer: Initiate a turning/repositioning schedule every 2 hours to relieve pressure).
Shift to "Unstageable" or "DTPI": "A wound is covered with 80% black, hard eschar. How should the nurse document this?" (Answer: Unstageable pressure injury).
Shift to "Patient Education": "Which statement by a family member caring for an immobile patient indicates understanding of pressure injury prevention?" (Answer: "I will help reposition him every two hours, even during the night.").
Nursing Clinical Practice GuideClinical Scenario: You are a nurse on a rehabilitation unit. Mr. Johnson, a 65-year-old with a T6 spinal cord injury (SCI), has been primarily wheelchair-bound for the past month. During your morning assessment, you assist with his hygiene and notice a wound on his sacrum. The skin is gone, and you see yellowish, stringy material and some reddish, moist tissue. Deep within the wound, you can see pale yellow, globular material.
Nursing Intervention Strategy:
1AssessmentPerform a comprehensive wound assessment using the TIME framework: Tissue (non-viable vs. viable), Infection/Inflammation, Moisture balance, Edges (undermining?). Measure length, width, depth. Note odor, exudate amount/type, and peri-wound skin condition. Document the stage as 3 because subcutaneous fat (the globular material) is visible.
2Care PlanningThe primary goals are to prevent worsening, manage exudate, promote granulation tissue, and prevent infection. Collaborate with the wound care nurse.
3Implementation
Pressure ReliefStrict adherence to a turning and repositioning schedule (every 2 hours while in bed, pressure relief lifts in the wheelchair every 15-30 minutes). Use a pressure-redistributing support surface (low-air-loss or alternating pressure mattress).
Wound CareBased on the wound characteristics (likely moderate exudate, slough present), the treatment may involve:
a.Cleansing: Use normal saline or a wound cleanser with each dressing change.b.Debridement: Autolytic debridement with a hydrogel or enzymatic debridement with collagenase ointment may be ordered to remove the slough.c.Dressing: Apply a foam dressing or calcium alginate to manage moisture. Secure with a film or composite border dressing.
NutritionCollaborate with the dietitian. Ensure adequate intake of protein, vitamin C, and zinc to support tissue repair.
4EvaluationMonitor for signs of healing (decreased size, increased granulation tissue, decreased exudate) or complications (increased redness, swelling, purulent drainage, fever – signs of infection).
Patient Safety and Precautions:- Never massage reddened areas over bony prominences, as this can cause further tissue damage from shear.
- When turning/repositioning, use a draw sheet or lift device to minimize shear and friction.
- Avoid using donut-shaped cushions, as they can increase pressure on the surrounding tissue and impair blood flow to the area at risk.
Nursing Procedure & Medication FlowWound Dressing Change for a Stage 3 Pressure Injury:
1Gather SuppliesClean gloves, sterile gloves, sterile saline, gauze, wound cleanser (if ordered), prescribed topical ointment (e.g., collagenase), appropriate secondary dressing (e.g., foam), tape, biohazard bag.
2. Perform Hand Hygiene and don clean gloves.
3. Remove Old Dressing gently. Discard in biohazard bag. Remove clean gloves.
4. Assess Wound (as described above).
5. Perform Hand Hygiene again and don sterile gloves.
6Cleanse WoundUse sterile gauze moistened with saline or wound cleanser. Clean from the center outward in a circular motion, using a new gauze for each swipe.
7Apply Medication/TopicalApply a thin layer of enzymatic debriding ointment (if ordered) directly to the slough.
8Apply DressingPlace the appropriate primary dressing (e.g., foam pad) into the wound cavity. Cover with a secondary secure dressing.
9. Dispose of all supplies, remove gloves, and perform hand hygiene.
10. Document wound appearance, measurements, care provided, and patient response.
A Word from Your Senior Nurse
"Pressure injuries are often called 'never events' because they are largely preventable with excellent nursing care. Your vigilant skin assessments and relentless commitment to turning schedules are what protect your patients. When you see a Stage 3 injury, don't just see a wound—see a story of prolonged pressure that your nursing actions can now help rewrite into a story of healing. On the NCLEX, they test this not just to see if you know the stages, but to see if you understand the profound responsibility nurses have in preventing human suffering. Connect the dots: immobility -> pressure -> ischemia -> necrosis -> ulcer. Your knowledge breaks that chain."
National Pressure Injury Advisory Panel — The organization that establishes the standardized definitions and staging system for pressure injuries.
Full-thickness skin loss — Loss of skin that extends through the epidermis and dermis into deeper tissue (subcutaneous fat, muscle, or bone).
Subcutaneous fat — The layer of fat tissue beneath the dermis. Its visibility in a wound bed is the key characteristic of a Stage 3 pressure injury.
Slough — Yellow, tan, or gray stringy or clumpy necrotic tissue (devitalized tissue) that adheres to the wound bed. It must be removed for healing to occur.
Braden Scale — A validated tool used to assess a patient's risk for developing pressure injuries based on six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.