Pressure Injury Stages

Question 1

stage 1

Answer 1

intact skin
nonblanchable

Question 2

stage 2

Answer 2

partial thickness skin loss w/ exposed dermis
wound bed pink or red
moist (might appear like ruptured blister)

Question 3

stage 3

Answer 3

full thickness skin loss
adipose tissue visible in the ulcer
granulation tissue and epibole (rolled wound edges) often present
slough or eschar might be visible
undermining or tunneling might occur
UNSTAGEABLE IF slough or eschar obscures the extent of tissue loss

Question 4

stage 4

Answer 4

full thickness skin loss
exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer
slough or eschar may be visible
epibole (rolled edges), undermining, and or tunneling often occurs
UNSTAGEABLE IF slough or eschar obscures the extent of the tissue loss

Question 5

unstageable

Answer 5

full-thickness skin and tissue loss where extent is obscured by slough or eschar
if slough or eschar are removed, stage 3 or 4 will be revealed

Question 6

deep-tissue

Answer 6

intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, purple discoloration, or epidermal separation revealing dark wound bed or blood-filled blister
pain and temp change often precede skin color change