Assessment
1. Stage 1: Skin is intact. Area s red and does not blanch with external pressure. Area may be painful, firm, soft, warmer, or cooler compared with adjacent tissue.
2. Stage 2: Skin is not intact. Partial thickness skin loss of the dermis occurs. Presents as a shallow open wound with a red-pink wound bed or as intact or open/ruptured serum filled blister.
3. Stage 3: Full-thickness skin loss extends into the dermis and subcutaneous tissues, and slough may be present. Subcutaneous tissue may be visible. Undermining and tunneling may or may not be present.
4. Stage 4: Full thickness skin loss is present with exposed bone, tendon, or muscle. Slough or eschar may be present. Undermining and tunneling may develop.