An unstageable pressure injury is characterized by?

• A. Unstageable pressure injury; full thickness skin loss with extent not determinable.
• B. Deep tissue injury
• C. Stage 2 pressure injury
• D. Suspected deep tissue injury

Answer: (A)

An unstageable pressure injury is defined by full-thickness tissue loss in which the depth of the wound cannot be determined because slough or eschar obscures the wound bed. The necrotic tissue hides how deep the damage goes, so you can’t assign a stage until that tissue is removed or debrided and the true extent is visible. This distinguishes it from other injuries: deep tissue injury shows a nonblanchable color change in intact skin indicating underlying tissue damage; stage II is partial-thickness skin loss with a visible wound bed; and suspected deep tissue injury involves a suspicious deep tissue injury color change under intact skin that hasn’t been confirmed yet. So the hallmark is full-thickness loss with depth not determinable due to covering tissue.