recognition matrix comparison
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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Dimension
Stage 1
Stage 2
Stage 3
Stage 4
Unstageable
Deep Tissue Injury
Appearance
- Intact skin, non-blanchable redness
- Shallow ulcer or serum-filled blister
- Pink-red wound bed, no slough
- Fat visible; no bone or tendon
- Slough/eschar may be present
- Exposed bone, tendon, or muscle
- Slough/eschar may be present
- Base obscured by slough or eschar
- Deep maroon/purple discoloration
- May be a blood-filled blister
Tissue depth
- Superficial; no tissue loss
- Partial-thickness (into dermis)
- Full-thickness into subcutaneous fat
- Full-thickness to bone/tendon/muscle
- Full-thickness, depth undetermined
- Deep tissue damage
- Skin may still be intact
Dressing / action
- Off-load, reposition q2h
- Protect skin (barrier cream)
- Keep moist — hydrocolloid or foam
- Off-load, reposition q2h
- Pack dead space loosely
- Off-load, reposition q2h
- Surgical consult for debridement
- Assess for osteomyelitis
- Pack dead space loosely
- Off-load, reposition q2h
- ★Debride to see the base
- Leave stable dry heel eschar intact
- Off-load, reposition q2h
- Off-load, reposition q2h
- Monitor; may evolve quickly
Provider order needed?
- 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
Watch-out / pearl
- ★Reversible if pressure relieved early
- Slough present means deeper than Stage 2
- Measure tunneling and undermining
- ★Highest infection risk (osteomyelitis)
- Measure tunneling and undermining
- Cannot stage until the base is visible
- Can deteriorate fast even with treatment
Appearance
Stage 1
- Intact skin, non-blanchable redness
Stage 2
- Shallow ulcer or serum-filled blister
- Pink-red wound bed, no slough
Tissue depth
Stage 1
- Superficial; no tissue loss
Stage 2
- Partial-thickness (into dermis)
Dressing / action
Stage 1
- Off-load, reposition q2h
- Protect skin (barrier cream)
Stage 2
- Keep moist — hydrocolloid or foam
- Off-load, reposition q2h
Provider order needed?
Stage 1
- No — prevention is nursing scope
Stage 2
- Usually no — moist dressing in scope
Watch-out / pearl
Stage 1
- ★Reversible if pressure relieved early
Stage 2
- Slough present means deeper than Stage 2
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Clinical Pearl
Stage by the deepest visible tissue — if the base is obscured by slough or eschar, it is Unstageable.
Component Topics
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Go further
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