Answer guided questions about what you see to identify the pressure injury stage — with plain-language definitions for each stage.
Look for discoloration suggesting damage beneath the surface, not ordinary redness.
This is the blanch test. Non-blanchable redness is the hallmark of stage 1.
Clinical decision support only — not a diagnosis. Staging can be subtle; when in doubt, document with photos and seek a second clinical opinion. Always follow your facility's protocol.
| Stage | What you see |
|---|---|
| 1 | Intact skin with localized redness that does not turn white when pressed. The area may feel warmer, cooler, firmer, or softer than nearby skin. |
| 2 | Partial-thickness skin loss — top layers broken, dermis exposed. Pink/red moist wound bed; may appear as an intact or ruptured serum-filled blister. No fat or deeper structures visible. |
| 3 | Full-thickness skin loss into the fatty layer. Fat is visible; muscle, tendon, and bone are not exposed. Tunneling or undermining may be present. |
| 4 | Full-thickness skin and tissue loss with muscle, tendon, ligament, cartilage, or bone directly visible or palpable. Tunneling and undermining are common. |
| Unstageable | Full-thickness loss, but true depth hidden by slough and/or eschar covering the wound bed. Re-stage once the covering is removed. (Stable eschar on a heel is typically left undisturbed.) |
| sDTI | Suspected deep tissue injury — intact or broken skin with persistent deep red, maroon, or purple discoloration or a blood-filled blister, suggesting underlying tissue damage. May evolve rapidly; monitor closely. |
Stage 1: intact skin with non-blanchable redness. Stage 2: partial-thickness skin loss with exposed dermis. Stage 3: full-thickness skin loss with visible fat. Stage 4: full-thickness loss with exposed muscle, tendon, or bone. Plus Unstageable (depth obscured by slough/eschar) and Suspected Deep Tissue Injury.
Stage 2 is partial-thickness skin loss — only the top layers are broken and the dermis is exposed. Stage 3 is full-thickness skin loss extending into the fatty layer below, where fat becomes visible.
The wound is full-thickness, but its true depth cannot be determined because slough or eschar covers the wound bed. Once the covering is removed, it is re-staged.
Intact or broken skin with persistent deep red, maroon, or purple discoloration (or a blood-filled blister), suggesting damage to underlying tissue. It may evolve rapidly and warrants close monitoring.
Reviva documents stage changes across every visit — with photo evidence, so nothing gets lost between assessments.
See Reviva