Steps for Assessment
1. Perform head-to-toe assessment. Conduct a full body skin
assessment focusing on bony prominences and pressure-
bearing areas (sacrum, buttocks, heels, ankles, etc.).
2. For the purposes of coding, determine that the lesion being
assessed is primarily related to pressure and that other
conditions have been ruled out. If pressure is not the
primary cause, do not code here.
3. Reliance on only one descriptor is inadequate to determine
the staging of a pressure injury between Stage 1 and deep
tissue injury (see definition of “deep tissue injury” on page
M-24). The descriptors are similar for these two types of
injuries (e.g., temperature [warmth or coolness]; tissue
consistency [firm or boggy]).
4. Check any reddened areas for ability to blanch by firmly pressing a finger into the reddened
tissues and then removing it. In non-blanchable reddened areas, there is no loss of skin color
or pressure-induced pallor at the compressed site.
5. Search for other areas of skin that differ from surrounding tissue that may be painful, firm,
soft, warmer, or cooler compared to adjacent tissue. Stage 1 may be difficult to detect in
individuals with dark skin tones. Visible blanching may not be readily apparent in darker skin
tones. Look for temperature or color changes as well as surrounding tissue that may be
painful, firm, or soft.
DEFINITIONS
STAGE 1 PRESSURE
INJURY
An observable, pressure-
related alteration of intact
skin whose indicators, as
compared to an adjacent or
opposite area on the body,
may include changes in one
or more of the following
parameters: skin temperature
(warmth or coolness); tissue
consistency (firm or boggy);
sensation (pain, itching);
and/or a defined area of
persistent redness in lightly
pigmented skin, whereas in
darker skin tones, the injury
may appear with persistent
red, blue, or purple hues.
NON-BLANCHABLE
Reddened areas of tissue
that do not turn white or pale
when pressed firmly with a
finger or device.
M0300A: Number of Stage 1 Pressure Injuries (cont.)