# 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?

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> subject: Adult Health

## 문제

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?

## 보기

1. Intact skin with non-blanchable redness and warmth to touch
2. Partial-thickness skin loss with exposed dermis and pink wound bed
3. Full-thickness skin loss with visible subcutaneous fat and possible slough **✔ 정답**
4. Full-thickness skin and tissue loss with exposed bone and tendon

**정답: 3**

## 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.

## 심화 해설

Understanding Pressure Injury Staging

Pressure injuries are localized damage to the skin and underlying soft tissue, usually over a bony prominence, resulting from intense and/or prolonged pressure. The staging system, as defined by the National Pressure Injury Advisory Panel (NPIAP), is a critical framework for assessment, documentation, and guiding treatment. Accurate staging is essential, yet conventional visual assessment is highly dependent on individual experience and often shows limited consistency [2]. This is why deep learning models are being developed to support objective staging [1,3,4]. The key to differentiating stages lies in identifying the deepest anatomical structure visible in the wound bed.

Analyzing the Options

Let's break down each option by its defining anatomical characteristics.

**Option 1: Intact skin with non-blanchable redness and warmth to touch**

This describes a Stage 1 Pressure Injury. The skin is intact, but there is a localized area of non-blanchable erythema. Non-blanchable means the redness does not turn white when you press on it, indicating that ischemia has already caused damage to the capillary bed. The tissue is not yet broken, but it is a critical warning sign. In patients with darker skin tones, the area may appear differently than the surrounding skin, and changes in sensation, temperature, or firmness may precede visual color changes.

**Option 2: Partial-thickness skin loss with exposed dermis and pink wound bed**

This is the hallmark of a Stage 2 Pressure Injury. The wound is partial-thickness, meaning the epidermis and part of the dermis are lost, but deeper structures like subcutaneous fat are not visible. The wound bed is viable, moist, and pink or red. It may also present as an intact or ruptured serum-filled blister. The presence of a pink, viable wound bed without slough or deeper tissue exposure is the defining feature here.

**Option 3: Full-thickness skin loss with visible subcutaneous fat and possible slough**

This is the correct description of a Stage 3 Pressure Injury. In a Stage 3 injury, the damage extends through the entire dermis into the subcutaneous layer. Adipose (fat) tissue is visible in the wound bed. Granulation tissue and rolled wound edges (epibole) are often present, and slough (yellow, tan, gray, green, or brown non-viable tissue) or eschar may obscure the view. The depth of a Stage 3 injury varies by anatomical location; areas with significant adipose tissue, like the sacrum, can have very deep Stage 3 wounds. Critically, bone, tendon, and muscle are not exposed.

**Option 4: Full-thickness skin and tissue loss with exposed bone and tendon**

This defines a Stage 4 Pressure Injury. The tissue destruction extends through the skin and subcutaneous fat, exposing deep structures such as fascia, muscle, tendon, ligament, cartilage, or bone. Osteomyelitis is a serious potential complication at this stage. Slough and eschar are common, and undermining and tunneling are frequently present.

Why Option 3 is the Best Answer

The question asks for the finding most indicative of a Stage 3 injury. The pathognomonic feature that distinguishes a Stage 3 from a Stage 2 is the presence of full-thickness skin loss with visible subcutaneous fat. It is distinguished from a Stage 4 by the absence of deeper structure exposure such as bone or tendon. The development of automated staging models, such as the two-stage deep learning framework combining object detection and image classification, focuses precisely on identifying these visual hallmarks—like the presence of subcutaneous fat—to improve diagnostic accuracy and reduce subjectivity in real-world clinical workflows [3]. The YOLOv8-based real-time detection system similarly aims to enable rapid and objective staging by recognizing these specific tissue-level characteristics, overcoming the limitations of manual assessment [4]. Therefore, the visualization of subcutaneous fat in a full-thickness wound is the defining characteristic that confirms a Stage 3 pressure injury.References (research sources)

- [2]Development and preliminary clinical validation of a mobile health application for pressure injury staging in ICU patients.Research articleSheng H, Hu C, Zhang D, Zhu Z, Xu D. (2026) · DOI: 10.3389/fmed.2026.1820690

- [3]Novel two-stage deep learning framework for automated pressure injury classification.Research articleLai TY, Chou YJ, Liu CY, Chen CW, Lin CT, Wang WC, Hsu Y, Hsieh ML, Chang SS. (2026) · DOI: 10.1136/bmjhci-2025-101636

- [4]Research on real-time detection and staging technology for pressure injuries in critically ill patients based on the YOLOv8 deep learning model.Research articleGuo F, Cao N, Nie J, Guo W, Wang J. (2026) · DOI: 10.3389/fpubh.2026.1781481

## 임상 시나리오

Pressure Injury Staging GuideKey Anatomical Landmarks for NCLEX & Practice
A Stage 3 Pressure Injury involves full-thickness skin loss. The defining visual cue is visible subcutaneous fat in the wound bed. Slough or eschar may be present, but they do not obscure the depth of tissue loss. Undermining and tunneling may also occur.

Differentiate from a Stage 4 injury, where deeper structures like bone, tendon, or muscle are directly visible. A Stage 2 injury is partial-thickness with an exposed dermis and a shiny or dry pink wound bed, while a Stage 1 shows intact skin with non-blanchable erythema.

CautionIf slough or eschar completely obscures the wound bed, the injury is unstageable. Do not guess Stage 3 or 4 until the base is visible. Deep tissue pressure injury presents as persistent, non-blanchable deep red, maroon, or purple discoloration of intact or non-intact skin.

## 핵심 개념

- **Stage 3 Pressure Injury** — Full-thickness skin loss in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location.
- **Non-blanchable Erythema** — Redness of the skin that does not turn white when pressure is applied, indicating localized ischemia and the hallmark of a Stage 1 pressure injury.
- **Slough** — Soft, moist, devitalized (dead) tissue that may be yellow, tan, gray, or green and can be loose or firmly adherent to the wound bed.
- **Subcutaneous Fat** — The deepest layer of the skin, located below the dermis, consisting of adipose tissue. Its exposure is the key indicator of a full-thickness Stage 3 injury.

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