Select the stage of the pressure ulcer shown in the given image.

DSSSB 14 August 2024

Medical & Surgical Nursing

Easy

Appeared in: DSSSB 14 August 2024

Explanation

The image shows a localized area of intact skin with a persistent purple or maroon discoloration, which is the defining characteristic of a Suspected Deep Tissue Injury (sDTI).
Unlike a Stage 1 injury, which presents as non-blanchable redness (erythema), the purple/maroon color of an sDTI signifies damage to the underlying soft tissues at the bone-muscle interface.
This type of injury results from intense and/or prolonged pressure and shear forces.
Although the skin is intact, a DTI is considered a serious injury because it can rapidly deteriorate, revealing a full-thickness wound (Stage 3 or 4).

Option A: Stage 4 involves full-thickness skin and tissue loss with exposed bone, muscle, or tendon. The skin in the image is clearly intact.
Option B: Stage 2 is defined by partial-thickness skin loss, presenting as a shallow open ulcer or a blister. The skin in the image is not broken.
Option C: Stage 3 involves full-thickness skin loss where subcutaneous fat is visible. The skin in the image is intact.

Clinical Relevance

Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Staging of pressure injuries based on visual assessment as background academic context rather than a clinical decision trigger.
Correctly identifying a Suspected Deep Tissue Injury is critical for patient safety. It is not a 'bruise' or a minor Stage 1 injury; it signals significant underlying damage and a high risk for rapid decline into a severe, full-thickness wound.
Nursing priority for an sDTI is immediate and complete pressure offloading of the area to prevent further ischemia and tissue death. This is more urgent than for a stable Stage 1 injury.
What if? If the area in the image was red instead of purple and blanched with pressure, it would not be a pressure injury but rather reactive hyperemia, a normal response to pressure. If it was red and did not blanch, it would be a Stage 1 pressure injury.

How to Approach the Question

First, carefully analyze the image provided, paying close attention to the color of the lesion and the integrity of the skin.
Note that the skin is intact, which immediately rules out Stage 2, 3, and 4 pressure injuries as they all involve broken skin.
Next, focus on the color. The lesion is a deep purple/maroon, not red (erythema).
Recall the definitions of pressure injury stages. Stage 1 is defined by non-blanchable redness. A persistent purple or maroon discoloration of intact skin is the specific definition of a Suspected Deep Tissue Injury (sDTI).
Evaluate the given options. Since sDTI is the correct diagnosis based on visual evidence and is provided as an option, select it.
If sDTI were not an option, you would recognize the question is flawed, as the image does not fit the other stages, but sDTI is the most accurate classification.

Concept Tested & Keywords

Concept Tested: Staging of pressure injuries based on visual assessment.
Stem keywords: pressure ulcer, stage, image
Lead-in keywords: Select
Clinical cues: The image shows intact skin with a deep purple/maroon discoloration on the heel, which is a key indicator for a specific type of pressure injury.

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E6 Nursing Fundamentals Potter Perry 12e Part 6 pp. 70-72, 69-71

E6 Nursing Fundamentals Taylor p. 557-559