Study topic
Wound and pressure injury care
NCLEX wound chapter: pressure-injury staging in words, prevention for immobile clients, deep tissue injury cues, and surgical wound infection signs.
Wound items on this topic are almost always staging from a description and prevention for the client who cannot turn alone. Learn the words; do not rely on a photo to carry the answer.
Stage from the description
| Stage / category | What the stem describes |
|---|---|
| Stage 1 | Intact skin, localized non-blanchable redness |
| Stage 2 | Partial-thickness open area or blister |
| Stage 3 | Full-thickness to fat; no bone/tendon/muscle |
| Stage 4 | Bone, tendon, or muscle visible |
| Deep tissue injury | Maroon/purple intact skin, often boggy/warm |
| Unstageable | Base hidden by slough or eschar |
Staging is a clinical description skill. Photos can mislead; the exam will give you the tissue depth in words.
Prevention for the immobile client
- Turn and reposition on a schedule (commonly every 2 hours unless ordered otherwise).
- Keep heels floated; use pillows to keep bony prominences off the mattress.
- Manage moisture; clean gently; barrier cream as ordered.
- Reduce shear when boosting up in bed — lift, don’t drag.
- Support protein/calorie intake as allowed.
Safety
For Stage 1 sacral redness: offload and protect. Massaging the spot is contraindicated.
Surgical wound infection cues
| Report | Often expected early |
|---|---|
| Spreading redness, warmth, purulent drainage, fever, odor, wound separation | Mild edge pinkness and scant serous drainage in the first days |
Priority map
| Picture | First move |
|---|---|
| Intact non-blanchable sacral red | Stage 1 — offload, don’t massage |
| Full-thickness with fat only | Stage 3 |
| Maroon boggy intact skin | Deep tissue injury pathway |
| Immobile client | Turn, offload heels, dry skin |
| Wound with pus + fever | Report infection signs |
Must know
- 1Stage 1: intact skin, non-blanchable erythema.
- 2Stage 2: partial-thickness; shallow open ulcer or blister.
- 3Stage 3: full-thickness to subcutaneous fat; no bone/tendon/muscle exposed.
- 4Stage 4: exposed bone, tendon, or muscle.
- 5Deep tissue injury: intact skin with persistent non-blanchable deep red/maroon/purple, often boggy/warm.
- 6Prevention: reposition on a schedule, keep skin clean/dry, offload sacrum/heels, nutrition/hydration, reduce shear.
- 7Stage 1 care: offload and protect — do not massage reddened bony areas.
- 8Surgical wound infection cues: increasing redness, warmth, purulent drainage, fever, separating edges — report.
Memory hooks
Intact red that won’t blanche = 1
If the skin is still closed and the redness stays when pressed, think Stage 1.
Fat visible, no bone = 3
Full-thickness with subcutaneous fat but no bone/tendon/muscle is Stage 3.
Don’t rub the red bone
Massaging non-blanchable redness over a bony prominence worsens tissue injury.
How it's tested
Stems describe a sacral finding in words and ask the stage, or ask which prevention actions are appropriate for Stage 1. Distractors massage the redness or call maroon intact skin a simple bruise.