Pressure Injury Staging
AssessmentThe steps
- Stage 1: intact skin, non-blanchable redness. Darker skin tones: look for color DIFFERENCE from surrounding skin, temperature, firmness — redness is unreliable
- Stage 2: partial-thickness loss — shallow open wound or intact/ruptured blister. Pink, moist. NO slough
- Stage 3: full-thickness — fat visible. May have slough, undermining, tunneling. No bone/tendon/muscle
- Stage 4: full-thickness with exposed bone, tendon, or muscle
- Unstageable: base obscured by slough/eschar — you can't stage what you can't see
- Deep Tissue Injury (DTI): intact skin, deep purple/maroon or blood blister — the damage is underneath and evolving
🛡 Never skip
Stages never go backwards in documentation — a healing stage 4 is a 'healing stage 4,' not a stage 2 Photograph and measure per policy on discovery: length × width × depth, undermining clock positions Present-on-admission documentation within your facility's window protects the patient AND the record — hospital-acquired vs POA is a big deal
Common mistakes
- Staging a moisture-associated skin damage (MASD) as a pressure injury — different cause, different plan
- Calling an unstageable wound 'stage 4' — if eschar covers the base, it's unstageable
- Missing DTIs on dark skin by hunting for 'redness'
Source: NPIAP Staging System; Ignatavicius, Medical-Surgical Nursing, 10th ed.Reference only — verify against your facility's policy.
