The clinic nurse is assessing a client who is being treated for depression and suicidal ideation

2.
Educational objective:
Stage 2 pressure injuries have partial-thickness skin loss (abrasion, blister, or shallow crater). The skin blisters or forms an open sore, and the area around the sore may be red and irritated.

• Stage 1: Intact skin with nonblanchable redness
• Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the dermis or epidermis; the wound bed is red or pink and may be shiny or dry
• Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle, or bone; tunneling may be present
• Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar (scabbing, dead tissue) may be present; undermining and tunneling may be present
• Pressure injuries are described as "unstageable" if the base is covered by necrotic tissue or eschar