A nurse is doing a skin assessment on a nursing home resident. On turning the bed bound resident non-blanchable redness is noted over the sacral area. The nurse knows this is what stage of pressure injury?

A. Stage 3: Stage 3 pressure injuries involve full-thickness skin loss, extending into the subcutaneous tissue. The wound may present as a deep crater with possible undermining or tunneling. Non-blanchable redness without skin loss does not meet the criteria for stage 3. B. Stage 1: Stage 1 pressure injuries are characterized by intact skin with non-blanchable erythema over a bony prominence. The skin may appear red in lighter-skinned individuals or may show persistent discoloration in darker-skinned individuals. The tissue is at risk but there is no open wound, making early identification and pressure relief critical to prevent progression. C. Stage 2: Stage 2 pressure injuries involve partial-thickness skin loss, affecting the epidermis and possibly the dermis. They may present as shallow open ulcers or intact/ruptured blisters. Non-blanchable redness alone without skin breakdown does not qualify as stage 2. D. Unstageable: Unstageable pressure injuries involve full-thickness tissue loss where the base of the ulcer is covered by slough or eschar. Since the skin in this case is intact and only erythematous, the injury cannot be classified as unstageable. E. Stage 4: Stage 4 pressure injuries involve full-thickness tissue loss with exposure of muscle, bone, or supporting structures. The presence of intact skin with non-blanchable redness does not indicate the extensive tissue destruction characteristic of stage 4 injuries.