Pressure Injury Staging and Wound Care
Stage I-IV, unstageable, deep tissue injury, dressing selection.
Pressure injuries staged by depth. NCLEX tests staging and basic dressing principles.
Stages
Stage I: intact skin, non-blanchable erythema. Stage II: partial-thickness, superficial dermal loss, looks like abrasion or shallow open ulcer. Stage III: full-thickness, fat visible, no bone/tendon. Stage IV: full-thickness, bone/tendon/muscle exposed. Unstageable: full-thickness, base obscured by slough/eschar. DTI: deep tissue injury, intact or non-intact skin with persistent non-blanchable deep red/purple discoloration.
Dressings
Stage I-II: hydrocolloid, foam. Stage III-IV with exudate: alginate, foam. Dry wounds: hydrogel. Heavy exudate: alginate. Infected: silver dressings, frequent changes.
Prevention
Turn q2h. Pressure-redistributing surfaces. Skin assessment daily. Heel offloading. Nutrition (protein). Hydration. Continence management.
Frequently asked
Eschar, debride?
Heel pressure injury with stable eschar: don't debride (protective). Elsewhere: debride to assess and treat.
Wet-to-dry dressings still standard?
Falling out of favor. Damage healthy tissue. Modern moist dressings preferred.
Quick check
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