Lesson 40: NCLEX Pressure Ulcers Staging

If a nurse chooses to ignore any of our NCLEX pressure ulcer prevention tips, one day someone could turn the patient over and see any of the following pictures. NOT for the faint at heart.

Stage 1- Skin is intact with non blanchable areas of redness, skin feels warm, firm, painful. This stage may be hard to see in patients with darker skin tones.

Stage 2-  Shallow open ulcer with red/pink wound bed. No slough is present. Stage 2 ulcers can also be seen as intact or open blisters, abrasions, or shallow craters.

Stage 3- Full thickness skin loss with some subcutaneous fat may be visible but bone, tendon, or muscle tissue are not exposed. Stage 3 may include undermining and tunneling.

Stage 4-  Full thickness loss with bone, tendon, muscle involvement. Slough/eschar may be present, tunneling is usually present.

Unstageable- Full thickness tissue loss where base of the ulcer is covered by slough or eschar. There is no way to tell what is underneath the covered surface.

Remember:

Keep patient's skin clean and dry
Turn, turn, turn it really takes about 2 minutes
Document skin assessments each shift, you don't want the Nurse Manager blaming one of these on you!

Thanks for studying with me.