Wound, Ostomy and Continence Nurses Society (WOCN) Practice Exam

What is the definition of an unstageable pressure injury?

1. Partial thickness with exposed muscle

2. Full-thickness skin and tissue loss obscured by necrotic tissue

3. Localized area with hematoma

4. Pressure injury at risk for infection

The correct answer is: Full-thickness skin and tissue loss obscured by necrotic tissue

An unstageable pressure injury is defined as a full-thickness skin and tissue loss where the extent of the injury is obscured by necrotic tissue, slough, or eschar. This means that the visible portion of the wound does not allow for a clear assessment of the underlying tissue and the true depth of the injury is unknown until the necrotic material is removed. In this context, the presence of necrotic tissue complicates the evaluation of the pressure injury, making it impossible to properly stage it according to established criteria (such as those provided by the National Pressure Injury Advisory Panel). This situation requires careful management, as it often indicates a significant loss of tissue that could pose a higher risk for complications, including deeper infection or systemic effects. The other options do not accurately represent the characteristics of an unstageable pressure injury. For instance, partial thickness with exposed muscle pertains to a different category and suggests a different level of injury. A localized area with hematoma describes a bruising phenomenon rather than a pressure injury, and a pressure injury at risk for infection does not specifically address the classification or staging of pressure injuries. Understanding the definition of unstageable pressure injuries is crucial for effective diagnosis, treatment planning, and potential prevention of complications