How are pressure ulcers staged, and what is one nursing intervention to prevent them?

• A. Stage I non-blanching erythema; Stage II partial thickness skin loss; Stage III full thickness; Stage IV full thickness with exposure; Intervention: regular repositioning and pressure-relieving devices
• B. Stage II non-blanching erythema; Stage III partial thickness; Stage IV full thickness; Intervention: heat therapy
• C. Stage I non-blanching erythema; Stage II full thickness; Stage III partial thickness; Intervention: increased moisture
• D. Stage I partial thickness; Stage II non-blanching erythema; Stage III full thickness; Intervention: rapid dressing changes

Answer: (A)

Staging pressure ulcers reflects how deep the tissue damage goes, from shallow skin involvement to damage that exposes deeper structures. Stage I is non-blanchable erythema of intact skin, indicating early tissue injury without open ulcer. Stage II involves partial-thickness skin loss, often presenting as a shallow open ulcer or blister. Stage III is full-thickness skin loss with damage to or necrosis of subcutaneous tissue, which may look like a crater. Stage IV is the deepest, with full-thickness tissue loss exposing bone, tendon, or muscle, and may include slough or eschar. To help prevent ulcers, the nursing focus is on relieving pressure and protecting bony prominences, using regular repositioning and pressure-relieving devices such as specialized mattresses or cushions. Other options either mix up the depth definitions or suggest measures that don’t align with standard prevention practices.