Which statement best characterizes Stage II pressure injury?

• A. Full-thickness skin loss with exposure of bone, tendon, or muscle.
• B. Partial-thickness skin loss with exposed dermis; a shallow open ulcer with a red-pink wound bed.
• C. Intact skin with nonblanchable redness.
• D. Deep tissue injury.

Answer: (B)

Stage II pressure injury reflects partial-thickness skin loss that involves the epidermis and/or dermis. The wound appears as a shallow open ulcer with a red or pink wound bed and may present as a ruptured or intact serum-filled blister. There is no exposed bone, tendon, or muscle, and slough is not present. This distinguishes it from full-thickness injuries that extend through deeper tissues into fat, muscle, or bone, and from deep tissue injuries, which start as nonintact skin with a deeper, often purplish area of tissue damage. It also differs from a Stage I injury, which is intact skin with nonblanchable redness rather than an open wound.