Measure with the patient in a consistent position; length head-to-toe, width side-to-side, depth at the deepest point with a moistened sterile applicator; document undermining and tunneling by clock position (e.g. 2 cm undermining at 10 o’clock).
Stage pressure injuries by the deepest visible tissue; do not down-stage a healing injury (a healing Stage 4 remains a healing Stage 4, not a Stage 2).
Assess the wound bed after cleansing, in good light; estimate tissue percentages and photograph per agency policy.
Palpate the periwound for induration and warmth and compare the two limbs or sides where applicable.
Assess pain before and during the dressing change and pre-medicate per order when indicated.
Use clean or sterile technique per the wound and the order; maintain a no-touch technique for the wound bed.
Reconcile the dressing found in place against the order; note if a prior dressing was saturated, dislodged, or incorrect.
Compare every parameter to the prior visit’s measurements and description to establish trajectory.
