Patient and Wound Assessment
Assess the person, then the wound
Begin with etiology, duration, and prior treatments, including what failed and why. Capture medications (steroids, anticoagulants, immunosuppressants, vasopressors), comorbidities (diabetes with A1c, peripheral artery disease, venous insufficiency, renal disease, obesity, immobility), nutrition (unintentional weight loss, intake, albumin or prealbumin), continence, cognition, pain, support system, and goals of care. Vascular screening includes pulses, Doppler, and ankle-brachial index: 0.9 to 1.3 is normal, below 0.9 suggests arterial disease, and above 1.3 suggests calcified, noncompressible vessels requiring toe pressures. Screen for neuropathy with the 10-g monofilament.
Describe the wound in reproducible terms
Record location and landmarks, length by width by depth (head-to-toe axis for length), undermining and tunneling by clock face plus depth, tissue types as percentages of the wound bed, exudate amount and character, odor, periwound skin (maceration, erythema, induration, callus), wound edges (rolled, epibole), and pain. Validated tools such as PUSH or Bates-Jensen make serial comparison possible.
Pressure injury staging
Stage 1 is intact skin with non-blanchable erythema; Stage 2 is partial-thickness dermal loss or a blister; Stage 3 is full-thickness loss not through fascia; Stage 4 is full-thickness with exposed bone, tendon, muscle, or fascia; unstageable means slough or eschar hides the base; deep tissue pressure injury is a persistent deep red, maroon, or purple area or blood blister.
Traps and a rule of thumb
Never downstage an improving pressure injury; document it as a healing Stage 3 if that was its deepest extent. Do not call moisture-associated skin damage a Stage 1 injury, and do not call a bruise a deep tissue injury. If you can see or probe bone, it is Stage 4.