Pressure Injury Staging: 1–4, Unstageable, DTI
The NCLEX shows you a pressure injury and expects the correct stage. Stage by the deepest tissue you can actually see — appearance, depth, dressing, and whether a provider order is needed all follow from the stage. If slough or eschar hides the base, you cannot stage it: it is Unstageable until debrided.
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Comparison
- Intact skin
- non-blanchable redness
- Shallow open ulcer or blister
- pink-red bed
- Visible fat
- slough may be present
- Exposed bone, tendon, or muscle
- Base obscured by slough or eschar
- Non-blanchable deep maroon/purple
- Intact — no open wound
- Partial-thickness (into dermis)
- Full-thickness into subcutaneous fat
- Full-thickness to bone/tendon/muscle
- Full-thickness, depth undetermined
- Deep tissue damage
- may still be intact
- Off-load, reposition q2h
- protect skin
- Keep moist — hydrocolloid or foam
- Fill dead space
- pack loosely (alginate)
- Surgical debridement
- manage infection
- ★Debride to stage — NOT stable dry heel eschar
- Off-load
- monitor — may evolve quickly
- No — prevention is nursing scope
- Usually no — moist dressing in scope
- Often yes — advanced dressing/debride
- Yes — surgical consult
- Yes — debridement order to stage
- Monitor in scope
- escalate if it worsens
- ★Reversible if pressure relieved early
- Slough present means deeper than Stage 2
- Measure tunneling and undermining
- ★Highest infection risk (osteomyelitis)
- Cannot stage until the base is visible
- Can deteriorate fast even with treatment
Stage 1
- Intact skin
- non-blanchable redness
Stage 2
- Shallow open ulcer or blister
- pink-red bed
Stage 1
- Intact — no open wound
Stage 2
- Partial-thickness (into dermis)
Stage 1
- Off-load, reposition q2h
- protect skin
Stage 2
- Keep moist — hydrocolloid or foam
Stage 1
- No — prevention is nursing scope
Stage 2
- Usually no — moist dressing in scope
Stage 1
- ★Reversible if pressure relieved early
Stage 2
- Slough present means deeper than Stage 2
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Stage by the deepest visible tissue — if the base is obscured by slough or eschar, it is Unstageable.
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