Stage 1: Intact skin with non-
blanchable redness of a localized
area usually over a bony prominence.
Darkly pigmented skin may not have
visible blanching; its color may differ
from surrounding area.
Stage 2: Partial thickness loss of
dermis presenting as a shallow open
ulcer with a red pink wound bed,
without slough. May also present as
an intact or open/ruptured serum-
fi lled blister.
Stage 3: Full thickness tissue loss.
Subcutaneous fat may be visible but
bone, tendon or muscle are not exposed.
Slough may be present but does not
obscure the depth of tissue loss. May
include undermining and tunneling.
Stage 4: Full thickness tissue loss
with exposed bone, tendon or
muscle. Slough or eschar may be
present on some parts of the wound
bed. Often include undermining and
tunneling.
Unstageable: Full thickness tissue
loss in which the base of the ulcer is
covered by slough (yellow, tan, gray,
green or brown) and/or eschar (tan,
brown or black) in the wound bed.
Suspected Deep Tissue Injury (sDTI): Purple or maroon localized area of discolored
intact skin or blood-fi lled blister due to damage of underlying soft tissue from pressure
and/or shear. The area may be preceded by tissue that is painful, fi rm, mushy, boggy,
warmer or cooler as compared to adjacent tissue.
Pressure Ulcer Staging
Stage 1: Intact skin with non-
blanchable redness of a localized
area usually over a bony prominence.
Darkly pigmented skin may not have
visible blanching; its color may differ
from surrounding area.
Stage 2: Partial thickness loss of
dermis presenting as a shallow open
ulcer with a red pink wound bed,
without slough. May also present as
an intact or open/ruptured serum-
fi lled blister.
Stage 3: Full thickness tissue loss.
Subcutaneous fat may be visible but
bone, tendon or muscle are not exposed.
Slough may be present but does not
obscure the depth of tissue loss. May
include undermining and tunneling.
Stage 4: Full thickness tissue loss
with exposed bone, tendon or
muscle. Slough or eschar may be
present on some parts of the wound
bed. Often include undermining and
tunneling.
Unstageable: Full thickness tissue
loss in which the base of the ulcer is
covered by slough (yellow, tan, gray,
green or brown) and/or eschar (tan,
brown or black) in the wound bed.
Suspected Deep Tissue Injury (sDTI): Purple or maroon localized area of discolored
intact skin or blood-fi lled blister due to damage of underlying soft tissue from pressure
and/or shear. The area may be preceded by tissue that is painful, fi rm, mushy, boggy,
warmer or cooler as compared to adjacent tissue.
Pressure Ulcer Staging
Stage 1: Intact skin with non-
blanchable redness of a localized
area usually over a bony prominence.
Darkly pigmented skin may not have
visible blanching; its color may differ
from surrounding area.
Stage 2: Partial thickness loss of
dermis presenting as a shallow open
ulcer with a red pink wound bed,
without slough. May also present as
an intact or open/ruptured serum-
fi lled blister.
Stage 3: Full thickness tissue loss.
Subcutaneous fat may be visible but
bone, tendon or muscle are not exposed.
Slough may be present but does not
obscure the depth of tissue loss. May
include undermining and tunneling.
Stage 4: Full thickness tissue loss
with exposed bone, tendon or
muscle. Slough or eschar may be
present on some parts of the wound
bed. Often include undermining and
tunneling.
Unstageable: Full thickness tissue
loss in which the base of the ulcer is
covered by slough (yellow, tan, gray,
green or brown) and/or eschar (tan,
brown or black) in the wound bed.
Suspected Deep Tissue Injury (sDTI): Purple or maroon localized area of discolored
intact skin or blood-fi lled blister due to damage of underlying soft tissue from pressure
and/or shear. The area may be preceded by tissue that is painful, fi rm, mushy, boggy,
warmer or cooler as compared to adjacent tissue.
Pressure Ulcer Staging
Stage 1: Intact skin with non-
blanchable redness of a localized
area usually over a bony prominence.
Darkly pigmented skin may not have
visible blanching; its color may differ
from surrounding area.
Stage 2: Partial thickness loss of
dermis presenting as a shallow open
ulcer with a red pink wound bed,
without slough. May also present as
an intact or open/ruptured serum-
fi lled blister.
Stage 3: Full thickness tissue loss.
Subcutaneous fat may be visible but
bone, tendon or muscle are not exposed.
Slough may be present but does not
obscure the depth of tissue loss. May
include undermining and tunneling.
Stage 4: Full thickness tissue loss
with exposed bone, tendon or
muscle. Slough or eschar may be
present on some parts of the wound
bed. Often include undermining and
tunneling.
Unstageable: Full thickness tissue
loss in which the base of the ulcer is
covered by slough (yellow, tan, gray,
green or brown) and/or eschar (tan,
brown or black) in the wound bed.
Suspected Deep Tissue Injury (sDTI): Purple or maroon localized area of discolored
intact skin or blood-fi lled blister due to damage of underlying soft tissue from pressure
and/or shear. The area may be preceded by tissue that is painful, fi rm, mushy, boggy,
warmer or cooler as compared to adjacent tissue.
Pressure Ulcer Staging
