Stage 1 |
Intact skin with nonblanchable redness of a localized area usually over a bony prominence.
Darkly pigmented skin may not have visible blanching;
its color may differ from the surrounding area. |
Stage 2 |
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.
May also present as an intact or open/ruptured serum-filled blister. |
Stage 3 |
Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle
are not exposed. Slough may be present but does not obscure the depth of tissue loss.
May include undermining and tunneling. |
Stage 4 |
Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be
present on some parts of the wound bed. Often include undermining and tunneling. |
Unstageable |
Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan,
gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. |