# A nurse is auditing pressure injury documentation on a medical unit. Each entry lists the wound findings and the classification that was charted. Which charted classifications are accurate? Select all that apply.

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> subject: Mobility/Immobility  
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## Question

A nurse is auditing pressure injury documentation on a medical unit. Each entry lists the wound findings and the classification that was charted. Which charted classifications are accurate? Select all that apply.

1

Ischium: full-thickness wound, fat visible, 2 cm tunnel, no bone or muscle seen; charted as Stage 4.

2

Gluteal cleft: diffuse shallow erosions with irregular edges after incontinence; charted as Stage 2.

3

Sacrum: shallow open area with a pink, moist wound bed and no slough; charted as Stage 2.

4

Left nare: shallow ulcer under the nasal cannula tubing on the mucosa; charted as mucosal, not staged.

5

Right heel: intact skin, deep maroon area that does not blanch, boggy on palpation; charted as Stage 1.

6

Left heel: dry, stable, adherent black eschar with no redness or drainage; charted as unstageable.

## Explanation

The shallow wound with a pink moist bed is Stage 2, a mucosal injury under a device is not staged, and stable heel eschar is unstageable. A maroon boggy area over intact skin is a deep tissue pressure injury, not Stage 1; incontinence erosions are moisture-associated skin damage, not Stage 2; and tunneling with fat but no bone or muscle is still Stage 3.

## In-depth explanation

Quick answer
Options 3, 4, and 6 are accurate. The heel, gluteal-cleft, and ischial entries each mislabel a near-neighbour category.

Why this is correct
Stage 2 is partial-thickness loss with a viable pink or red moist dermal bed and no slough. Pressure injuries on mucous membranes (often from devices such as cannulas or tubes) cannot be staged because mucosa has no layers matching skin anatomy. Stable, dry, adherent eschar on a heel means the depth cannot be seen, so the injury is unstageable and the eschar is usually left in place.

Easy analogy or mental picture
Think of staging as measuring the depth of a hole: you can only number the hole when you can see its floor (unstageable if covered), when the surface is really skin (mucosa is not staged), and when pressure, not wetness, dug it.

Memory hook
Maroon and boggy = deep tissue. Wet and diffuse = moisture, not pressure. Fat plus tunnel = still Stage 3; bone, tendon, or muscle = Stage 4.

NCLEX decision rule
Before accepting a stage, ask three questions: Is it skin? Can I see the base? Is the cause pressure? Then match the deepest visible tissue, not the size, drainage, or tunneling.

Why the other choices are wrong
Heel maroon area (option 5): tempting because the skin is intact like Stage 1, but a purple or maroon, boggy, non-blanchable area signals deep tissue pressure injury, which can evolve rapidly. Gluteal-cleft erosions (option 2): tempting because they are shallow like Stage 2, but diffuse, irregular erosions from incontinence are incontinence-associated dermatitis, a moisture problem, and NPIAP advises against calling it Stage 2. Ischial wound (option 1): tempting because tunneling looks deep, but the stage is set by the deepest visible tissue; with fat and no bone, tendon, or muscle, it is Stage 3.

References
1NPIAP Resources: pressure injury staging definitionsDefinitions of Stages 1-4, unstageable, deep tissue, and mucosal membrane pressure injury

## Clinical scenario

Scenario
A wound-care nurse audits pressure injury documentation for several clients on a medical unit, comparing the charted findings with the NPIAP classification system.

## Key concepts

- **Deep tissue pressure injury** — Intact or non-intact skin with persistent non-blanchable deep red, maroon, or purple discoloration from pressure and shear at the muscle-bone interface.
- **Mucosal membrane pressure injury** — Injury to a mucous membrane, usually from a medical device, that is documented but not staged.
- **Incontinence-associated dermatitis** — Moisture-associated skin damage from urine or stool that causes diffuse erosion and is not classified as a pressure injury.

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