A nurse is caring for a client who has a pressure injury on the coccyx. Which of the following findings should indicate to the nurse that the wound is a stage III pressure injury?
Explanation & Rationale
A. Bone is exposed within the wound: Exposure of bone indicates a stage IV pressure injury, which involves full-thickness tissue loss with exposed muscle, tendon, or bone. This is more severe than stage III. B. The skin is reddened and intact: Reddened, intact skin corresponds to a stage I pressure injury, which involves non-blanchable erythema without skin breakdown. C. Subcutaneous fat is visible: Stage III pressure injuries involve full-thickness skin loss, where subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. This finding is consistent with stage III classification. D. Slough and eschar is present: While slough and eschar may be present in stage III or IV injuries, the presence alone is not sufficient to determine stage. The key characteristic for stage III is full-thickness tissue loss with visible subcutaneous fat without exposed deeper structures.