2 Pressure Injury Staging Concepts

Assess the cause and tissue

Pressure injury stages describe the tissue damage that can be seen or directly assessed, not the wound’s size or how long it has been present. Before assigning a stage, identify the likely cause and examine both the wound and surrounding skin. An open or discolored area should not automatically be called a pressure injury: moisture, trauma, vascular disease, and other conditions can cause skin damage.

Distinguish the four stages

Use the deepest tissue that is visible or directly palpable to distinguish the stages.

• Stage 1: Skin is intact, with a localized, persistent non-blanchable color change. Appearance may differ across skin tones. Changes in temperature, firmness, or sensation can also be clues. In darker skin tones, assess change from the person’s usual skin color and compare temperature, firmness, and sensation with nearby tissue.

• Stage 2: Partial-thickness skin loss exposes the dermis. The wound bed is viable, pink or red, and moist. A serum-filled blister may be intact or ruptured. Fat and deeper tissues are not visible, and slough and eschar are absent.

• Stage 3: Full-thickness skin loss exposes adipose tissue. Slough, eschar, undermining, or tunneling may occur, but fascia, muscle, tendon, ligament, cartilage, and bone are not exposed.

• Stage 4: Full-thickness skin and tissue loss exposes or makes directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. Exposed tendon, for example, is consistent with Stage 4.

The central distinctions are exposed dermis in Stage 2, visible adipose without exposed deeper structures in Stage 3, and exposed or directly palpable deeper structures in Stage 4.

Recognize obscured and deep damage

Unstageable describes full-thickness skin and tissue loss when slough or eschar obscures the extent. If that covering is removed, Stage 3 or Stage 4 damage will be revealed. Stable heel eschar should not be softened or removed.

A Deep tissue pressure injury is characterized by persistent, non-blanchable deep red, maroon, or purple discoloration, or by epidermal separation revealing a dark wound bed or blood-filled blister. Such an injury can evolve or resolve. When visible deeper tissue damage is present, classify it according to the exposed tissue instead.

Separate pressure injury from other damage

Assess the cause and appearance rather than assigning a pressure injury stage just because skin is open, wet, or discolored. Moisture-associated skin damage, such as moist, irritated skin across the perineal area and skin folds in a person with incontinence, should not be labeled Stage 2. A skin tear caused by adhesive tape removal is traumatic damage; document the traumatic cause rather than staging it as a pressure injury. Vascular disease and other conditions can also cause skin damage that should not automatically be classified as pressure injury.

A device-related pressure injury is staged according to its visible tissue damage, and the device-related cause can also be noted. A device-related cause does not determine the stage. Mucosal membrane pressure injuries are documented but not staged.

Document stages and healing

Pressure injuries do not have to progress through the stages in a required sequence. Do not reverse-stage a healing wound: when its original stage is known, document it as healing at that original stage. For example, a previously documented Stage 4 injury that is smaller and covered with granulation tissue remains documented as a healing Stage 4 pressure injury, rather than being reclassified as Stage 3 or Stage 2.

• Pressure injury staging

• Mucosal membrane pressure injury