A client with a Stage II pressure injury on the sacrum is most likely to present with which finding?
Explanation & Rationale
A. Partial-thickness skin loss involving epidermis and/or dermis: Stage II pressure injuries are characterized by partial-thickness loss of skin, affecting the epidermis and possibly the superficial dermis. The wound may present as a shallow open ulcer with a red or pink wound bed, or as an intact or ruptured blister. The underlying tissue is still protected, and there is no exposure of deeper structures such as muscle, tendon, or bone. B. Full-thickness skin loss exposing muscle or bone: This finding corresponds to Stage III or Stage IV pressure injuries. Stage III involves full-thickness skin loss with damage or necrosis of subcutaneous tissue, whereas Stage IV extends to muscle, bone, or supporting structures. Stage II wounds do not involve these deeper layers. C. Eschar obscuring the wound bed: Eschar is necrotic tissue that can cover Stage III or IV pressure injuries, often appearing black, brown, or tan. In Stage II pressure injuries, the wound bed is typically viable and pink, without necrotic tissue obscuring visualization. D. Intact skin with non-blanchable erythema: This is indicative of a Stage I pressure injury, where the skin remains intact but shows persistent redness or discoloration that does not blanch when pressure is applied. Stage II involves partial-thickness skin loss, which distinguishes it from Stage I.