A patient has a pressure injury on the sacrum with visible subcutaneous fat and a deep depression below the skin level. What stage of pressure injury would you document?

A. Suggest that the patient focus on their medical condition rather than family concerns: Redirecting the patient away from their emotional concerns dismisses their feelings and does not provide holistic, patient-centered care. Emotional support is essential in terminal illness.

B. Encourage the patient to discuss their feelings openly and involve the family in the care process: Facilitating open discussion allows the patient to express fears and emotions, strengthens family communication, and provides psychological support. This approach respects the patient’s values and promotes holistic care.

C. Avoid discussing emotional concerns to prevent upsetting the patient further: Avoidance can increase anxiety and isolation. Addressing emotional concerns directly, with empathy, supports coping and provides comfort during end-of-life care.

D. Refer the patient to pastoral care without addressing their concerns directly: Referral can be beneficial, but it should complement—not replace—the nurse’s direct engagement. The nurse should first acknowledge and validate the patient’s feelings before involving additional resources.

A. Stage II: Stage II pressure injuries involve partial-thickness skin loss with exposed dermis. There may be a shallow open ulcer, blister, or abrasion, but subcutaneous fat is not visible. The described wound is deeper, so it does not fit Stage II criteria.

B. Stage I: Stage I pressure injuries are characterized by intact skin with non-blanchable erythema. There is no tissue loss or ulceration, making this stage inconsistent with the wound described.

C. Stage III: Stage III pressure injuries involve full-thickness skin loss with visible subcutaneous fat. The wound extends below the dermis into the subcutaneous tissue, creating a deep depression. This description matches the characteristics of a Stage III pressure injury.

D. Stage IV: Stage IV pressure injuries involve full-thickness skin and tissue loss with exposed bone, tendon, or muscle. Since the description mentions subcutaneous fat but no bone, tendon, or muscle exposure, Stage IV is not appropriate.