2025-07-31·7 min read·Clinical Nursing
Pressure Injury Staging: NCLEX Nursing Review
NPUAP pressure injury staging system, prevention strategies, and wound care management.
Pressure Injury Stages
- Stage 1: Non-blanchable redness on intact skin
- Stage 2: Partial-thickness skin loss - shallow open ulcer or blister
- Stage 3: Full-thickness skin loss - subcutaneous fat visible, bone/tendon NOT visible
- Stage 4: Full-thickness tissue loss - bone, tendon, or muscle exposed
- Unstageable: Wound bed covered by slough (yellow) or eschar (black)
- Deep tissue injury: Purple or maroon discoloration of intact skin
Prevention - KEY for NCLEX
- Reposition every 2 hours
- Use the Braden Scale to assess risk (score ≤18 = at risk)
- Keep skin clean and dry, moisturize
- Adequate nutrition (protein, vitamin C, zinc)
- Use pressure-redistributing surfaces
- Float heels off the bed
Treatment
- Stage 1-2: Keep clean, moisture barrier, transparent film or hydrocolloid
- Stage 3-4: Wound care specialist, debridement, negative pressure therapy
- NEVER stage a pressure injury in reverse (once Stage 3, it does not become Stage 2 as it heals)
Study more at Physiological study guide and Physiological flashcards.