Bed Sore Stages

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• Intact skin with "nonblanchable" redness of a localized area (usually over a bony prominence).   ”Nonblanchable” means that the redness does not fade. 
• Darkly pigmented skin may not have visible blanching (fading redness); its color may differ from the surrounding area.
• The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
• Stage I may be difficult to detect in individuals with dark skin tones.

• Partial thickness loss of the top layer of skin (called the dermis) presenting as a shallow open ulcer with a red pink wound bed.
• The wound may appear as an intact  or ruptured fluid (serum) filled blister.
•  It may appear as a shiny or dry shallow ulcer without bruising.
• This area may be very painful.

• Full thickness tissue loss.
• Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.
• Slough (dead tissue) may be present but does not obscure the depth of tissue loss.
• May include undermining, meaning that there is overhanging skin edges at the margin of the wound, so the pressure ulcer is larger in area at its base than at the skin surface.
• May include tunneling, meaning that a tunnel has formed within the wound into other tissues

The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

•  Full thickness tissue loss with with exposed bone, tendon, or muscle.
• Slough,  eschar, or necrotic tissue can be present on some parts of ulcer.
• Often undermining & tunneling present.

The depth of a Stage IV pressure ulcer varies by anatomical location.  

• Full thickness tissue loss in which the base of the ulcer is covered and thus cannot be visualized to determine depth.
• The wound may be covered  by slough, a dead tissue, of yellow, tan, gray, green, or brown in color.
• The wound may be covered by eschar, a necrotic tissue that may appear tan, brown, or black.

Until enough of the slough/eschar is removed to expose the base of the ulcer, the true depth, and thus the stage cannot be determined.

• Often appears on the sacrum or heels.
• May appear with a purple, firm, and slightly warm area.
• May be difficult to identify in persons with dark pigmented skin.
• sDTI of the heel may appear as a blister that is blood-filled.