Pressure Injury Staging Comparison

Intact skin with non-blanchable localized redness; may appear violet or maroon in dark skin tones; area may feel warmer, cooler, firmer, or softer than surrounding skin

Skin intact — epidermis only affected; no open wound; microvascular changes indicate impaired perfusion

Act immediately — this is the warning sign. Increase repositioning frequency. Apply protective foam dressing to affected area. Assess Braden score and implement full prevention protocol.

Shallow open ulcer with pink or red, moist wound bed; OR intact or ruptured serum-filled blister; no slough or bruising (bruising suggests DTI)

Partial thickness dermis loss — epidermis and upper dermis destroyed; subcutaneous fat not visible; wound bed is viable (pink/red)

Moisture-retentive dressing (hydrocolloid, thin foam) to maintain moist wound environment. Relieve pressure. Manage moisture. Pain management — Stage 2 is often very painful due to exposed nerve endings.

Full thickness tissue loss; wound crater; subcutaneous fat may be visible; slough or eschar may be present but does not obscure depth; undermining and tunneling may be present

Epidermis, dermis, and subcutaneous fat involved; bone, tendon, and muscle are NOT visible or directly palpable

Assess and document wound dimensions (L×W×D), undermining, and tunneling. Moist wound healing approach. Consult wound care specialist. Nutritional support — protein and calories critical. Debridement per order if necrotic tissue present.

Full thickness tissue loss with exposed or directly palpable bone, tendon, or muscle; slough or eschar may be present on portions; undermining and tunneling common

All tissue layers destroyed — epidermis, dermis, subcutaneous fat, fascia; bone, tendon, or muscle directly exposed or palpable

Monitor for osteomyelitis (probe-to-bone test positive = presumed osteomyelitis). Multidisciplinary team required. Assess for systemic infection. Negative pressure wound therapy (NPWT) may be ordered. Surgical consult may be necessary.

Full thickness loss with wound bed obscured by slough (yellow, tan, gray, green) or eschar (tan, brown, black); true wound depth cannot be determined

Full thickness — actual depth hidden; once debrided, typically reveals Stage 3 or 4 wound. Exception: stable dry adherent heel eschar is not debrided

Document as unstageable. Assess for infection signs under eschar (odor, fluctuance, periwound changes). Debridement per provider order — do not debride without an order. Heel eschar exception: do not debride stable, dry, adherent heel eschar — it is a natural protective cover.

Non-blanchable deep red, maroon, or purple discoloration of intact or nearly intact skin; OR blood-filled blister; pain and temperature changes often precede visible changes

Damage at the bone-muscle interface from intense and/or prolonged pressure and shear; overlying skin may appear intact while deeper tissue is already necrotic

Immediate pressure relief. Monitor closely at every shift — may evolve rapidly to Stage 3 or 4 within hours or days despite optimal care. Notify provider. Document evolution carefully. Do not massage area over bony prominences.