Staging Pressure Ulcer
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Intact skin with non-blanchable redness (skin color remain unchanged under pressure/ persistent pink discoloration).
No blistering of the skin is observed.
Area may be painful, firm, mushy, boffy, soft, warmer or cooler than other area of skin.
Stage 1 pressure ulcer
Loss of epidermis
Partial thicknes loss of dermis.
Can be intact or open /ruptured serum filled or
serosangineous filled blister.
Shallow open ulcer with a red pink wound bed.
Shiny or dry shallow ulcer.
No slough or brusing
Stage 2 pressure ulcer
Subcutaneous fat may be visible but bone, tendons or muscles NOT exposed.
Full thickness tissue losse
Some Slough may be present.
May or May not include undermining and tunneling.
The wound base is visible.
Stage 3 pressure ulcer
Full thickness tissue loss with exposed bone, tendons or muscles.
Slough or eschar may be present.
Ulcer often include undermining and tunneling.
Stage 4 pressure ulcer
Thin blister over a dark wound bed.
Tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to other area.
Wound may further evolve and become covered by thin eschar.
Look like a bruise or blood blister. Does not form an ulcer.
Color is purple or maroon
Suspected Deep Tissue Injury (DTI)
Multiple pressure ulcer/ areas of tissue lost.
Eschar/Slough covers the wound bed.
Wound bed CANNOT be visualized.
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