A nurse notices a wound on a client that has exposed adipose tissue with full-thickness skin loss. What stage is this pressure injury?

A nurse notices a wound on a client that has exposed adipose tissue with full-thickness skin loss. What stage is this pressure injury?

• A. Stage 1
• B. Stage 2
• C. Stage 3
• D. Stage 4

Answer: (C)

The presence of exposed adipose tissue with full-thickness skin loss indicates that the wound is classified as a Stage 3 pressure injury. In this stage, there is damage through the epidermis and dermis that extends into the subcutaneous tissue, but it does not involve the underlying fascia, muscle, or bone. This classification is important for determining appropriate wound care and management strategies. Stage 1 involves intact skin with localized redness, while Stage 2 reveals partial-thickness skin loss presenting as a shallow open sore, exposed dermis, or blister. Stage 4 indicates a more severe injury where there is full-thickness loss with tissue necrosis or damage to underlying structures such as muscle or bone. The characteristics of the wound as described clearly match the definition of a Stage 3 pressure injury.

The presence of exposed adipose tissue with full-thickness skin loss indicates that the wound is classified as a Stage 3 pressure injury. In this stage, there is damage through the epidermis and dermis that extends into the subcutaneous tissue, but it does not involve the underlying fascia, muscle, or bone. This classification is important for determining appropriate wound care and management strategies.

Stage 1 involves intact skin with localized redness, while Stage 2 reveals partial-thickness skin loss presenting as a shallow open sore, exposed dermis, or blister. Stage 4 indicates a more severe injury where there is full-thickness loss with tissue necrosis or damage to underlying structures such as muscle or bone. The characteristics of the wound as described clearly match the definition of a Stage 3 pressure injury.