Wound Care
Core assessment
Wound care questions reward a systematic approach. Assess the whole patient first-perfusion, nutrition, glycemic control, mobility, incontinence, and pressure/shear exposure-then the wound: location, etiology, age, size, depth, tissue type, exudate, periwound skin, pain, and signs of infection. Accurate etiology drives the plan: pressure injuries need offloading; venous ulcers need compression after arterial status is checked; arterial ulcers need perfusion review; diabetic foot ulcers need offloading and vascular assessment; moisture-associated skin damage needs a barrier and removal of the moisture source.
Staging and traps
Pressure injury staging describes depth at initial assessment. Stage 1 is intact skin with nonblanchable erythema; stage 2 is partial-thickness loss with viable pink/red tissue or a blister; stage 3 is full-thickness loss with adipose visible but no fascia, muscle, tendon, cartilage, or bone; stage 4 exposes those deep structures. When slough or eschar obscures depth, document unstageable-do not guess. Deep tissue injury is intact or non-intact skin with persistent deep purplish/maroon discoloration. A common trap is labeling moisture-associated dermatitis as a pressure injury or reversing the stage as a wound heals. Do not sharply debride stable, dry ischemic heel eschar without vascular assessment. Infection is clinical: increasing pain, purulence, spreading erythema, warmth, or delayed healing-not wound culture alone.
Rule of thumb
Treat the cause, then manage moisture balance and protect periwound skin. Example: a 3-cm sacral ulcer covered by thick black eschar with no visible bone is documented as unstageable, not stage 3; if debridement later exposes bone, it becomes stage 4.