The nurse is caring for a 68-year-old client and notes an area of red and purple discoloration on the client's sacrum that is non-blanchable and boggy on palpation. A photo is placed in the client's Assessment. Which stage of pressure injury would be documented by the nurse?
A. Stage 1
B. Stage 4
C. Unstageable
D. Deep tissue injury
Answer (2)
The area described on the client's sacrum is indicative of a deep tissue injury due to its non-blanchable and boggy characteristics. This classification falls under the NPIAP staging for pressure injuries. Proper identification is crucial for effective treatment and management. ;
The pressure injury described is classified as a Deep Tissue Injury due to its non-blanchable and boggy characteristics. This classification indicates significant underlying tissue damage. Accurate staging is essential for effective treatment and management of the injury.
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