Pressure Injury Staging and Risk Assessment
Key Points
- Pressure injuries result from ischemic tissue damage caused by pressure, friction, and shear.
- Risk rises with moisture exposure, impaired mobility, reduced cognition, and poor nutrition or hydration.
- The Braden Scale standardizes risk stratification; lower scores indicate higher injury risk.
- Accurate staging (I-IV, deep tissue, unstageable) guides intervention urgency and monitoring.
Pathophysiology
Pressure injury develops when sustained force compresses soft tissue between external surfaces and bony prominences, reducing blood and lymph flow. Ischemia leads to inflammation, edema, necrosis, and possible ulceration.
Friction and shear worsen injury by damaging superficial skin and deeper vascular structures. Tissue injury can develop rapidly in patients unable to reposition independently.
Classification
- Stage I: Nonblanchable erythema over intact skin.
- Stage II: Partial-thickness skin loss with exposed dermis.
- Stage III: Full-thickness skin loss with visible adipose and possible slough.
- Stage IV: Full-thickness loss with exposed fascia, muscle, tendon, or bone.
- Unstageable/Deep tissue: Obscured depth by slough or eschar, or maroon/purple deep tissue pattern.
Nursing Assessment
NCLEX Focus
Prioritize risk recognition and stage accuracy, then match prevention or escalation intensity to findings.
- Assess moisture exposure, mobility, sensory perception, nutrition, cognition, and friction/shear.
- Use the braden-scale on admission and at scheduled reassessment points.
- Evaluate blanching response and persistent nonblanchable changes over bony prominences.
- Trend stage, wound-bed characteristics, and surrounding tissue changes to detect progression.
Nursing Interventions
- Implement individualized prevention bundles based on Braden risk level.
- Reposition regularly, offload pressure points, and reduce friction/shear during transfers.
- Keep skin clean and dry; use barrier protection for incontinence-associated moisture.
- Escalate stage progression, unstable tissue findings, or signs of infection promptly.
Staging Safety Issue
Inaccurate staging delays appropriate treatment and can mask clinical deterioration.
Pharmacology
| Drug Class | Examples | Key Nursing Considerations |
|---|---|---|
| topical-skin-protectants | Barrier creams | Reduce moisture-associated skin breakdown risk. |
| analgesics | Acetaminophen, opioids | Support tolerability of repositioning and wound care. |
Clinical Judgment Application
Clinical Scenario
A bedbound patient with urinary incontinence has new sacral nonblanchable erythema and a Braden score of 14.
Recognize Cues: Moisture burden, mobility limits, and low risk score. Analyze Cues: Pattern is consistent with high risk and early pressure injury development. Prioritize Hypotheses: Immediate priority is preventing progression from early-stage tissue injury. Generate Solutions: Intensify offloading, moisture control, and reassessment frequency. Take Action: Start targeted prevention bundle and document stage-specific findings. Evaluate Outcomes: Skin changes stabilize without deeper-stage progression.
Related Concepts
- integumentary-system - Baseline barrier vulnerability and skin-care priorities.
- moving-and-positioning-clients - Positioning technique directly affects pressure and shear loads.
- complications-of-immobility - Immobility amplifies pressure injury risk and consequences.
- wound-classification-framework - Pressure injury is a distinct wound class with staging requirements.
- delayed-wound-healing-factors-and-complications - Stage progression increases risk of delayed healing.
Self-Check
- Why does a lower Braden score change prevention intensity?
- How does nonblanchable erythema differ from transient pressure hyperemia?
- Which risk factors should trigger more frequent skin reassessment?