Pressure Injury Staging: Wound Care | @LevelUpRN
Level Up RN・2 minutes read
Stage 1 pressure injury: Damage limited to the epidermis, skin red, non-blanchable, intact. Stage 4 pressure injury: Full thickness skin loss, exposed bone, muscle, or tendon.
Insights
- Stage 1 pressure injury involves damage limited to the skin's top layer, appearing as red, non-blanchable skin that remains intact.
- Unstageable pressure injuries are characterized by wound bases covered in necrotic tissue, making it impossible to determine the depth of the injury, often presenting with escar or Slough, and potential deep tissue damage indicated by purple discoloration or blood-filled blisters.
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Recent questions
What is a Stage 1 pressure injury?
Damage limited to the epidermis, skin red, non-blanchable, intact.
What characterizes a Stage 2 pressure injury?
Open wound with partial thickness skin loss.
What defines a Stage 3 pressure injury?
Damage extends to subcutaneous tissue, no visible bone, tendon, or muscle.
What are the characteristics of a Stage 4 pressure injury?
Full thickness skin loss, exposed bone, muscle, or tendon.
How is an unstageable pressure injury defined?
Depth unknown due to necrotic tissue covering wound base.
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Summary
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Pressure Injury Stages: From Red Skin to Exposed Bone
- Stage 1 pressure injury: Damage limited to the epidermis, skin red, non-blanchable, intact.
- Stage 2 pressure injury: Open wound with partial thickness skin loss, damage to epidermis and dermis, wound base red and moist or filled blister.
- Stage 3 pressure injury: Damage extends to subcutaneous tissue, no visible bone, tendon, or muscle, undermining and tunneling possible.
- Stage 4 pressure injury: Full thickness skin loss, exposed bone, muscle, or tendon.
- Unstageable pressure injury: Depth unknown due to necrotic tissue covering wound base, may have escar (black substance) or Slough (creamy whitish yellow substance), deep tissue injury may show intact or non-intact skin with purple or maroon discoloration or blood-filled blister.
