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Stage 1 : Non-blanchable erythema of intact skin Characteristics include : Intact skin with a localized area of skin that does not turn white when pressed , possible changes in sensation , temperature or firmness that precede non-blanchable response .

Remember : Dark skin tones rarely show a blanchable response , so other qualities should be taken into account , such as taut , shiny or hardened skin .

Good to know : Purple or maroon discoloration may indicate a deep tissue pressure injury .

Stage 2 : Partialthickness loss of skin with exposed dermis Characteristics include : Wound bed is viable , pink or red , moist , and may present as an intact or ruptured serum-filled blister . The injury is a fairly shallow , but open wound .

Remember : You won ’ t see adipose ( fat ), deeper tissues , granulation tissue , slough and eschar .

Good to know : These injuries commonly result from adverse microclimate and shear at the pelvis and shear in the heel .

Stage 3 : Fullthickness skin loss Characteristics include : Fatty tissue is visible in the wound , and granulation tissue and epibole are often present . Slough and / or eschar may also be visible . Undermining and tunneling may occur .

Remember : Depth varies depending on injury location . Good to know : If slough or eschar obscures the extent of tissue loss , this is an Unstageable Pressure Injury .

Stage 4 : Full-thickness skin and tissue loss Characteristics include : Exposed or directly palpable fascia , muscle , tendon , ligament , cartilage or bone . Slough and / or eschar may be visible . Epibole , undermining and / or tunneling often occur .

Remember : Depth varies depending on injury location .

Good to know : Like a stage 3 , if slough or eschar obscures the extent of tissue loss , this is unstageable .

Deep tissue pressure injury Characteristics include : Persistent non-blanchable deep red , maroon or purple discoloration . Discoloration of intact or broken skin may also include a blood-filled blister .

Remember : Discoloration may appear differently in dark skin tones . Look for DTPIs after long surgical procedures .

Can a pressure injury stage change up or down ?

After DTPIs evolve , or unstageable pressure injuries are debrided , they can be numerically staged . However , the numerical pressure injury staging system doesn ’ t mean that injuries necessarily progress or heal in a linear fashion .

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