Pressure Injury Staging

Question 1

Stage 1 Pressure Injury

Answer 1

Intact skin with a localized area of non-blanchable redness, which may appear differently in darkly pigmented skin;
Presence of blanchable erythema or changes in sensation, temp, or firmness may precede visual changes
Color changes don’t include purple or maroon discoloration

Question 2

Stage 2 Pressure Injury

Answer 2

Partial-thickness loss of skin with exposed dermis; wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister
Adipose, deeper tissues not visible
Granulation tissue, slough, Escher not present

Question 3

Stage 3 Pressure Injury

Answer 3

Full-thickness loss of skin, adipose visible in ulcer and granulation tissue and episode present
Slough and/or eschar may be visible
Depth of tissue damage varies with each anatomical location
Undermining/tunneling may occur
Fascia, muscle, tendon, ligament, cartilage, and/or bone not exposed

Question 4

Stage 4 Pressure Injury

Answer 4

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer
Slough, eschar may be visible
Epibole, undermining, tunneling often occur
Depth of wound varies

Question 5

Unstageable Pressure Injury

Answer 5

Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer can’t be confirmed because is is obscured slough/eschar
If slough/eschar removed, stage 3 or stage 4 pressure injury will be revealed

Question 6

Deep Tissue Pressure Injury

Answer 6

Intact or non intact skin with localized area of persistent nonblanchable deep red, maroon or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister
Pain and temp change often precede skin color changes
This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface