Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and /or shear. The are may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared with adjacent tissue.

Further description:
Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed the wound may further evolve and become covered by thin eschar. Evolution may be round, esposeding additional layers of tissue even with optimal treatment. in.

Intact skin with a non-blanching redness of a localized area over a bony prominence. Darkly pigmented skin may not have a visible blanching; its color may differ from surrounding area.

Further description:
The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detest in the individual with dark skin tones. May indicate “at risk” persons (a heralding sign of risk) in.

Partial-Thickness loss of dermis presenting as a shallow open ulcer with a red pink bed, without slough. May also present as a intact or open/ruptured serum filled blister

Further description:
Presets as a shiny or shallow ulcer without slough or bruising. * This stage should not be used to describe skin tears tape burns, perineal dermatitis, maceration of denudement.
*Bruising indicating suspected deep tissue injury (DTI).

Full Thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the dept of tissue loss. May include undermine and tunneling.

Further description:
The depth of a Stage 3 Pressure ulcer varies by anatomical location. The bridge of the nose ear occiput and malleolus do not have sub cutaneous tissue and stage 3 ulcers can be shallow. In contrast areas of significant adiposity can develop extremely deep stage 3 pressure ulcers. Bone/Tendon is not visible or directly palpable.

Full thickness tissue loss with exposed bone tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often times include undermining and tunneling.

Further description:
The depth of a stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage 4 ulcers can extend into the muscle and or supporting structures (for example, fascia, tendon, joint capsule) making osteomyelitis possible. Exposed bone tendon is visible or directly palpable.