📚 Deeper Dive · Scenario 38 of 57

The Sore That Was Missed, In Depth

Pressure injury assessment & staging basics — the why behind offload-and-report
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Coach Katie
You already lived this with Mrs. Carter. Now let's understand it deeply — how skin breaks down, how you prevent it with your hands, and how you pass it on. Learn it, live it, share it.
Learn It

Finding a pressure injury: what to do, what never to do

Repositioning Mr. Sokolov, you find an open, reddened area over his sacrum. Finding a pressure injury starts a short, clear checklist — and one firm prohibition. You relieve the pressure (reposition him off it), protect the area, assess and measure it, and report and document accurately. And you never massage or rub it.

Think of a pressure injury like a leak in a dam you just discovered. Your first move isn't to study it for an hour — it's to take the pressure off, mark exactly what you see, and call the people who can fix it. Every minute of continued pressure lets the damage spread deeper.

Staging describes depth

Staging is simply a language for how deep the damage goes: Stage 1 is intact skin with redness that doesn't blanch (whiten) when pressed; Stage 2 is a shallow open sore or blister; Stage 3 reaches into the fatty tissue; Stage 4 exposes muscle, tendon, or bone. Two more descriptions sit outside that 1–4 depth scale — they are separate categories, not higher-numbered stages (there is no Stage 5 or Stage 6): when dead tissue (slough or eschar) hides the depth, it's unstageable; and a deep tissue injury starts at the muscle-bone interface and shows through as intact maroon or purple skin, or a blood-filled blister. As a student, you don't have to stage it perfectly — you describe what you see accurately and report, and the wound team confirms the stage.

Non-blanchable redness matters. Press a red area gently — if it stays red instead of whitening, blood flow is already compromised. That's a Stage 1 injury even with intact skin, and a signal to offload now. In darker skin tones a Stage 1 injury may not look red or blanch at all — compare the area to surrounding skin for changes in temperature, firmness, and color, not just visible redness.
📊 Reference — the Braden Scale for pressure-injury risk. Six subscales are each scored and added for a total from 6 to 23 — a lower score means higher risk:
• Sensory perception — ability to feel and respond to discomfort.
• Moisture — how wet the skin stays.
• Activity — how much the patient is up and moving.
• Mobility — ability to change position.
• Nutrition — usual food and fluid intake.
• Friction & shear — rubbing and sliding against surfaces.
Common risk bands: 19–23 minimal/no risk · 15–18 mild/at risk · 13–14 moderate · 10–12 high · 9 or below severe risk. Use the score to trigger prevention (turning schedule, support surface, moisture and nutrition care) — and remember clinical judgment can raise the risk level even when the number looks reassuring.

The prohibition — and the connection

Never massage or rub the injury or a reddened bony area (it worsens the damage), and never leave the patient lying on it. This is the same mindset as pressure-injury prevention: relieve pressure, protect the skin, and act early. Care and prevention are two ends of the same rope.