09/14/2026
🚨 Unstageable Pressure Injury: What Nurses Should Know
The wound depth cannot be determined because the base is covered by slough or eschar.
✅ Clean gently with prescribed wound cleanser
✅ Assess drainage, odour, edges and surrounding skin
✅ Apply the ordered dressing
✅ Reposition and relieve pressure
✅ Document and notify the wound-care team
⚠️ Never forcibly remove eschar. Stable, dry heel eschar is generally kept intact unless otherwise ordered.
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