A nurse assesses a client and finds a shallow, open wound on the coccyx with a pink-red wound bed and no slough or necrotic tissue. The wound does not extend through the dermis. How should the nurse document this wound?
- A.Stage 1 pressure injury
- B.Stage 2 pressure injury
- C.Stage 3 pressure injury
- D.Unstageable pressure injury
Show answer & rationale
Correct answer
B. Stage 2 pressure injury
Rationale
B is correct: A Stage 2 pressure injury presents as a partial-thickness loss of dermis, appearing as a shallow open ulcer with a pink-red wound bed, without slough or necrotic tissue. The skin layers above the subcutaneous tissue are involved but not penetrated. A is incorrect: Stage 1 is intact skin with non-blanchable erythema; there is no open wound. C is incorrect: Stage 3 involves full-thickness tissue loss extending through the dermis into subcutaneous tissue; fat may be visible but bone, tendon, and muscle are not exposed. D is incorrect: Unstageable wounds are covered by slough or eschar that prevents staging.
Key concepts