Integumentary System
Wound healing and assessment
Healing proceeds through hemostasis, inflammation (days), proliferation (granulation, contraction, epithelialization over weeks) and remodeling (months). Assess location, size, depth, edges, wound bed color, drainage amount and type, odor, periwound skin and pain. Clean, beefy red granulation is healthy; black eschar and yellow slough indicate necrotic tissue that may need debridement. Document in consistent units and measure the same way each time.
Pressure injuries
Stage 1 is intact skin with nonblanchable erythema; stage 2 is partial thickness loss; stage 3 is full thickness through subcutaneous tissue; stage 4 extends to muscle, tendon or bone. Unstageable means eschar or slough obscures the depth, and deep tissue pressure injury presents as persistent maroon or purple discoloration. A wound covered by eschar cannot be staged until the eschar is removed, and stable heel eschar is often left alone.
Burns and dressings
Use the rule of nines for adults: each arm 9 percent, each leg 18 percent, anterior trunk 18 percent, posterior trunk 18 percent, head 9 percent, perineum 1 percent. Superficial partial burns are painful and blanch; full thickness burns are leathery and insensate. Choose dressings by goal: moisture-retentive films for shallow dry wounds, hydrocolloids for light exudate, foams and alginates for heavy exudate, and avoid occlusive dressings on infected wounds.
Traps
Never massage over reddened skin, avoid whirlpool agitation on clean granulating wounds, and do not apply heat over acute infection or malignancy.
Rule of thumb: describe what you see and measure it; staging is a diagnosis of depth, not of size.