AIIMS Delhi NO - 2018: Which stage of bed sore is shown here?& x20;

AIIMS Delhi NO - 2018

Medical & Surgical Nursing

Easy

Appeared in: AIIMS Delhi NO - 2018

Explanation

The image displays a Stage 2 pressure injury.
This stage is defined by partial-thickness loss of the dermis, presenting as a shallow open ulcer with a red-pink, moist wound bed.
It can also appear as an intact or ruptured serum-filled blister.
In the given image, the skin is broken, and a shallow ulcer is visible, which are hallmark signs of a Stage 2 injury.
Deeper tissues like fat, muscle, or bone are not visible.

Option A: Grade-1 (Stage 1) pressure injuries involve intact skin with non-blanchable redness. The image clearly shows broken skin and an open ulcer, which rules out Stage 1.
Option C: Grade-3 (Stage 3) involves full-thickness skin loss where subcutaneous fat is visible. The wound in the image is shallow and does not extend into the fat layer.
Option D: Grade-4 (Stage 4) is the most severe, involving full-thickness skin and tissue loss with exposed bone, muscle, or tendon. The wound in the image is superficial and does not show any of these deep structures.

Clinical Relevance

Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Staging of pressure ulcers (bedsores) based on visual assessment as background academic context rather than a clinical decision trigger.
Accurate staging of pressure injuries is crucial for determining the appropriate treatment plan, including dressing selection and pressure-relieving interventions.
Early identification and intervention for Stage 1 and 2 injuries can prevent progression to more severe, harder-to-treat wounds, reducing patient morbidity and healthcare costs.
Nurses play a key role in preventing pressure injuries by conducting regular skin assessments (especially over bony prominences), ensuring adequate nutrition and hydration, and repositioning at-risk patients frequently (e.g., every 2 hours).

How to Approach the Question

First, carefully examine the image provided, paying close attention to the characteristics of the wound.
Identify the key features: Is the skin intact or broken? What is the color of the wound bed? How deep does the wound appear to be?
Note that the skin is broken, forming a shallow ulcer with a pink-red base. This indicates partial-thickness skin loss.
Recall the definitions of the four main stages of pressure injuries.
Compare the observed features with the staging criteria. Stage 1 has intact skin. Stage 2 has partial-thickness loss. Stage 3 has full-thickness loss with visible fat. Stage 4 has exposed bone/muscle.
Conclude that the features in the image (shallow ulcer, partial-thickness loss) perfectly match the description of a Stage 2 pressure injury.

Concept Tested & Keywords

Concept Tested: Staging of pressure ulcers (bedsores) based on visual assessment.
Stem keywords: bed sore, stage, pressure injury
Lead-in keywords: Which stage
Clinical cues: Image shows a shallow open ulcer with a red-pink wound bed, indicating partial-thickness skin loss.

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E6 Nursing Fundamentals Potter Perry 12e Part 6 p. 69-71

E6 Nursing Fundamentals Taylor pp. 560-562, 581-583