Stage 4 pressure sore is characterized by which finding?

• A. Exposed dermis, pink or red, moist
• B. Nonblanchable erythema with intact skin
• C. Full thickness loss of skin with fat visible, rolled wound edges
• D. Full thickness skin and tissue loss, exposed fascia, muscle tendon, bone, or cartilage

Answer: (D)

Stage IV pressure ulcers involve full-thickness tissue loss with exposure of deep structures such as fascia, muscle, tendon, or bone. The skin is completely breached and the wound bed reveals these underlying tissues, and there may be undermining or tunneling. This depth makes it the most severe stage, distinguishing it from earlier stages where the wound does not yet expose deeper structures: Stage I shows nonblanchable redness of intact skin; Stage II is partial-thickness loss with a shallow wound bed; Stage III is full-thickness loss with fat visible but no exposed muscle or bone.