What are the stages of pressure injuries?

Author: SCIRE Community Team | Reviewer: Susan Andrews | Published: 3 November 2017 | Updated: ~

Pressure injuries are classified by how severe they are as “stages” of injury. These stages can range from just a small amount of redness on the skin to a wound that travels all the way down to the bone. Determining which stage a pressure injury is can help you and your health team to measure the extent of wounds and figure out how to treat it.

Stages of Pressure Injury ( National Pressure Injury Advisory Panel ) 2

Stage 1 The skin is intact with an area of redness that does not go away after being off of it for 20 to 30 minutes.
Stage 2 There is a partially open wound that is the thickness of the skin (shallow) and typically red-pink in colour.
Stage 3 There is a full skin thickness opening (deeper than skin level) that has a mostly red or pink base with no bone or tendon visible. Minimal slough or it is called unstageable.
Stage 4 Full thickness skin opening which includes exposed bone, tendon and muscle and possibly slough. Both Stage 3 and 4 wounds may have tunnels or open areas that run under the skin.
Unstageable A wound that is covered with slough or black skin so it not open and the base of it cannot be seen. This type of sore is impossible to stage.
Deep tissue injury A wound that is dark purple or a blood filled blister. If the cause is addressed quickly these injuries can resolve without tissue loss but they can also develop into stage 4 pressure injuries depending on the extent of injury to the tissues.