Pressure Ulcer Staging

Question 1

Stage 1

Answer 1

Intact skin with non-blanchable redness. Area may be painful, firm, soft, warmer or cooler

Question 2

Stage 2

Answer 2

Partial thickness tissue loss of dermis. Open ulcer with red or pink wound bed. Intact or ruptured serum filled blister or shiny/dry ulcer without slough or bruising

Question 3

Stage 3

Answer 3

Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscles are not exposed. Slough may be present but doesn’t obscure depth of tissue

Question 4

Stage 4

Answer 4

Full thickness tissue loss with exposed bone, tendon, or muscle that is visible or directly palpable. Slough or eschar present