👤 By the CinnaRN Clinical Content Team🕐 Updated 2026-08-23🏷️ Basic Care & Comfort🔖 Free to read, print, and share
Also known as: pressure ulcer · bedsore · decubitus ulcer · pressure sore · bed sore · pressure injury staging
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Use this quick-reference guide to spot, treat, and prevent Pressure Injury (staging) on the NCLEX. Keep it handy during review and on exam day!
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📒 The 1-minute cheat sheet
📌 Stages
1: intact skin, nonblanchable red
2: partial, shallow open/blister
3: full, subq fat visible
4: bone/muscle/tendon exposed
📌 Other
Unstageable: slough/eschar covers
DTI: purple intact, boggy
🎓 Prevent
Turn q2h, off-load pressure
Keep skin dry, protein nutrition
📚 Pressure Injury (staging) — full study notes
The cheat sheet above is your quick recall card. These notes go deeper — what it is, what to do first, what must be reported, and what to teach.
A pressure injury is localized damage to skin and underlying tissue caused by prolonged pressure, usually over a bony prominence such as the sacrum, heels, hips, or elbows. Unrelieved pressure cuts off blood flow, leading to ischemia and tissue death. They are staged 1 through 4 by depth, plus unstageable and deep tissue injury. Prevention through repositioning is far easier than treatment, making this a key safety and quality indicator.
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Key points
Understand these first
Stage 1: intact skin with nonblanchable redness; in dark skin tones look for a change in color, temperature, or firmness.
Stage 2: partial-thickness loss with exposed dermis; appears as a shallow open ulcer or intact/ruptured blister.
Stage 3: full-thickness loss with visible subcutaneous fat; slough may be present but bone, tendon, and muscle are not exposed.
Stage 4: full-thickness loss with exposed bone, tendon, or muscle; high risk for osteomyelitis.
Unstageable: full-thickness loss where the base is obscured by slough or eschar so depth cannot be determined.
Deep tissue pressure injury: intact or non-intact skin with a persistent maroon or purple area or blood-filled blister.
Shear, friction, moisture, immobility, poor nutrition, and incontinence are major contributing risk factors.
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Nursing priorities
What to do, in order
Reposition immobile patients at least every 2 hours and use a turning schedule; reposition chair-bound patients hourly.
Use a validated risk tool (Braden scale) on admission and routinely to identify at-risk patients.
Keep skin clean and dry, manage incontinence promptly, and apply moisture barrier creams.
Use pressure-redistribution surfaces, float the heels off the bed, and avoid massaging bony prominences.
Optimize nutrition with adequate protein, calories, vitamin C, and zinc to support tissue repair.
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Red flags — report now
Escalate immediately
Spreading redness, warmth, purulent drainage, or foul odor signals infection; notify the provider.
Exposed bone or a sinus tract suggests possible osteomyelitis; escalate for imaging and culture.
Never massage reddened bony areas or position the patient directly on an existing pressure injury.
Do not elevate the head of bed above 30 degrees longer than needed; it increases sacral shear.
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Labs & values
Numbers to know
Albumin: low reflects poor nutrition and impaired healing (normal 3.5 to 5.0 g/dL)
Prealbumin: low indicates recent poor protein intake (normal 15 to 36 mg/dL)
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Patient teaching
What patients must know
Shift weight every 15 minutes when sitting and inspect the skin daily, using a mirror for hard-to-see areas.
Eat protein-rich foods and stay hydrated to keep skin healthy.
Keep skin moisturized but dry in skin folds, and report any new red or open areas early.
❓ Pressure Injury (staging): NCLEX FAQs
What are the priority nursing interventions for Pressure Injury (staging)?
Reposition immobile patients at least every 2 hours and use a turning schedule; reposition chair-bound patients hourly. Use a validated risk tool (Braden scale) on admission and routinely to identify at-risk patients. Keep skin clean and dry, manage incontinence promptly, and apply moisture barrier creams. Use pressure-redistribution surfaces, float the heels off the bed, and avoid massaging bony prominences.
What are the warning signs of Pressure Injury (staging) a nurse must report?
Spreading redness, warmth, purulent drainage, or foul odor signals infection; notify the provider. Exposed bone or a sinus tract suggests possible osteomyelitis; escalate for imaging and culture. Never massage reddened bony areas or position the patient directly on an existing pressure injury. Do not elevate the head of bed above 30 degrees longer than needed; it increases sacral shear.
What do I need to know about Pressure Injury (staging) for the NCLEX?
Stage 1: intact skin with nonblanchable redness; in dark skin tones look for a change in color, temperature, or firmness. Stage 2: partial-thickness loss with exposed dermis; appears as a shallow open ulcer or intact/ruptured blister. Stage 3: full-thickness loss with visible subcutaneous fat; slough may be present but bone, tendon, and muscle are not exposed. Stage 4: full-thickness loss with exposed bone, tendon, or muscle; high risk for osteomyelitis.
What patient teaching is important for Pressure Injury (staging)?
Shift weight every 15 minutes when sitting and inspect the skin daily, using a mirror for hard-to-see areas. Eat protein-rich foods and stay hydrated to keep skin healthy. Keep skin moisturized but dry in skin folds, and report any new red or open areas early.
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Quick Tip
Stage 1: intact skin with nonblanchable redness; in dark skin tones look for a change in color, temperature, or firmness.