Dermatology

Wound Care &
Skin Integrity

WestNet Medical • Module 05 • Wounds, Pressure Injury & Skin Dignity

WestNet Unified Health Platform • WestNet Catalog 731985456604 • ISBN 978-0-XXXXX-XXX-X (Pending)
CE Accreditation Path: ANCC • ACCME • CARNA
Last updated: June 2026

Core Learning Objective

Learners will read skin breakdown as a downstream signal — of nutrition, perfusion, immobility, moisture, and how a person is cared for — rather than a local skin problem. Stage pressure injuries accurately, assess wounds with the TIME framework, recognize dermatologic emergencies before they kill, and treat the whole person with prevention-first, observation-first, dignity-first care.

Published By

WestNet Medical Publications
A division of WestNet North America Inc.
medical.westnet.ca

Co-Published With

WestNet Humanitarian Services (WHS)
UN Supplier • Registered NGO
www.westnet.ngo

WestNet Catalog (UPC-A): 7 31985 45660 4
ISBN 978-0-XXXXX-XXX-X (Pending) • First Edition

7 31985 45660 4

WestNet Medical Publications

Continuing Education Information

Field	Detail
Module	05 of 12 — Dermatology / Wound Care
Contact Hours	2.5 (Pending ANCC / ACCME / CARNA approval)
Target Audience	RNs, LPNs, RPNs, Wound & Ostomy Nurses, Health Care Aides, Physiotherapists, Dietitians, Licensed Clinicians
Publication	WestNet Medical Publications • Catalog 731985456604 • ISBN Pending
Disclosure	Educational content. Does not replace facility policy, physician orders, wound-care formulary, or jurisdictional scope-of-practice requirements.

Stage pressure injuries (Stage 1–4, deep tissue injury, unstageable) using current NPIAP definitions
Assess any wound systematically with the TIME framework (Tissue, Infection/Inflammation, Moisture, Edge)
Apply an evidence-based prevention bundle (SSKIN) and adjust it to each patient’s risk profile
Differentiate uncomplicated cellulitis from necrotizing fasciitis and recognize LRINEC-style red flags
Recognize Stevens-Johnson syndrome / toxic epidermal necrolysis as a dermatologic emergency
Identify nutrition, perfusion, moisture, and mobility as the true drivers of healing — and treat them
Document skin and wounds with objective, observation-first, dignity-preserving language

Program Preface

§ 01

This module was developed from bedside wound-care workflow analysis across North American acute and long-term care settings — not from product brochures or dressing-company education alone. WestNet HealthOS was built because the conventional wound workflow too often treats the hole in the skin while ignoring the body that produced it.

Module 05 is not anti–wound-care. It is anti–surface-only care — the kind that orders an expensive dressing for a Stage 4 sacral wound while the patient is malnourished, dehydrated, immobile, and lying on the same pressure point for the eighth hour running.

WestNet Position

The dressing is the smallest part of wound healing. Nutrition, perfusion, pressure relief, moisture balance, and consistent human attention do the work. A wound that will not heal is almost always a body that is not being supported to heal. Observe the whole person first; choose the dressing last.

Skin Is Never “Just Skin”

§ 02

The skin is the body’s largest organ and its most honest one. It cannot hide what is happening underneath. A breakdown over the sacrum, the heel, or the ischium is not a local accident — it is the visible endpoint of a chain: too little protein and fluid to rebuild tissue, too little blood flow to deliver it, too much pressure for too long, too much moisture macerating the surface, and too few hands turning and checking the patient.

Clinical Reality

When staff lead with the dressing, they stop seeing the body. The wound becomes a task on the cart rather than a message from the patient. That is not wound care — that is housekeeping with a sterile field.

Dignity at the Bedside

Every wound assessment requires exposing skin that the patient may have spent a lifetime keeping private. Knock. Explain before you uncover. Drape what you are not examining. Ask permission, warm your hands, work gently, and narrate what you are doing. The same trauma-informed gentleness taught in Module 07 applies here: to a survivor of assault, being uncovered and touched without consent can re-open an old wound far deeper than the one on the skin.

The Four Pillars of WestNet Skin Integrity

§ 03

Skin heals on four legs. Remove any one and the wound stalls no matter how advanced the dressing. These pillars are the lens through which every wound in this module is read.

Pillar I

Nutrition

Tissue is rebuilt from protein, calories, vitamin C, zinc, and fluid. A malnourished patient cannot close a wound — no dressing substitutes for the building blocks. Screen, feed, and involve a dietitian early (see Module 03).

Pillar II

Perfusion & Oxygen

Healing needs blood. Hypotension, peripheral arterial disease, anaemia, smoking, and uncontrolled diabetes starve the wound bed. Assess pulses, capillary refill, and glucose — a wound on an ischaemic limb will not heal until flow is restored.

Pillar III

Pressure, Moisture & Mobility

Unrelieved pressure and shear kill tissue from the inside out; excess moisture macerates it from the outside in. Reposition, offload, manage incontinence, and keep skin clean and balanced — not too wet, not too dry.

Pillar IV

Attention & Dignity

Wounds are found, prevented, and healed by people who look. Consistent skin inspection, gentle handling, and respect for the exposed patient are clinical interventions — not courtesies. The most reliable wound prevention tool is a clinician who pays attention.

Pressure Injury Staging

§ 04

Accurate staging drives the right plan and the right resources. Staging describes the deepest tissue type visible — it is not a healing timeline, and a healing wound is never “back-staged” (a healed Stage 4 is a “healed Stage 4 pressure injury,” not a Stage 2). The NPIAP system^[2] is summarised below; the interactive Stager in §13 lets you practise.

The Six Categories

Stage 1 — intact skin, localized non-blanchable erythema. Stage 2 — partial-thickness loss, exposed dermis (shallow, pink/red, moist; or an intact/ruptured serum blister). Stage 3 — full-thickness loss into subcutaneous fat; slough may be present but bone/tendon not exposed. Stage 4 — full-thickness loss with exposed/palpable bone, tendon, or muscle. Deep Tissue Injury (DTI) — intact or non-intact skin with persistent deep red, maroon, or purple discolouration. Unstageable — full-thickness loss where the base is obscured by slough or eschar; depth cannot be determined until the bed is cleared.

Do Not Confuse

Moisture-associated skin damage (incontinence dermatitis), skin tears, and arterial/venous ulcers are not pressure injuries and must not be staged as such. Stable, dry, intact eschar on an ischaemic heel is the body’s natural cover — do not debride it without confirming perfusion.

Clinical Pearls

•Reposition q2h and offload the heels. The heel has almost no padding between skin and bone — float it off the bed on a pillow under the calf rather than under the heel itself; never let a Stage 1 sit unturned.
•Run the SSKIN bundle every shift — Surface, Skin inspection, Keep moving, Incontinence/moisture, Nutrition & hydration (see §7). Prevention is cheaper, faster, and kinder than any dressing.
•Deep purple or maroon discolouration of intact skin is a deep-tissue injury — not a bruise and not a Stage 1. The damage is already at the bone–muscle interface and may open into a Stage 3/4 within days; offload and escalate now.
•Healing needs protein, perfusion, and moisture balance. A wound that stalls is a whole-body signal: feed the tissue, restore the blood supply, and keep the bed moist–not–wet — the skin is reporting on the body behind it.

At-a-Glance — Stage Cues & Escalation. A bedside quick-reference for the six categories. Stage describes the deepest visible tissue; an obscured base cannot be numbered. Use it to orient, not to replace a hands-on assessment.

Category	What you see	Escalate / act when
Stage 1	Intact skin, localized non-blanchable erythema (often over a bony prominence)	Offload immediately and intensify SSKIN — a Stage 1 left unturned becomes an open wound
Stage 2	Partial-thickness loss; shallow pink/red moist bed, or an intact/ruptured serum blister	Find and remove the pressure source; escalate if it deepens or shows infection signs
Stage 3	Full-thickness loss into subcutaneous fat; slough may be present, no bone/tendon visible	Wound-care referral; reassess nutrition and perfusion; escalate if undermining or stalling
Stage 4	Full-thickness loss with exposed/palpable bone, tendon, or muscle	Specialist (wound/surgical) referral now — osteomyelitis and sepsis risk are real
Deep Tissue Injury	Persistent deep red, maroon, or purple intact or non-intact skin — not a bruise	Offload and escalate now; it can open into a Stage 3/4 within days
Unstageable	Full-thickness loss whose base is hidden by slough or eschar; depth unknown	Refer for debridement (per scope/order) — but never debride stable dry eschar on an unperfused limb

Reading the wound	Healing — leave it to work	Infected / deteriorating — escalate
Tissue in the bed	Beefy-red granulation, advancing	Increasing slough or new necrosis; friable, bleeds easily
Exudate	Stable or decreasing, serous	Rising volume, cloudy/purulent, new odour
Peri-wound & edge	Pink epithelium advancing from the edge	Spreading erythema, warmth, oedema; rolled or static edge
Pain & the patient	Stable or easing; patient systemically well	New or rising pain; fever, tachycardia — suspect spreading infection

When to Escalate — Don’t Sit On It

Any of the following warrants prescriber/specialist review rather than another dressing change: a wound that has not shrunk in 2–4 weeks of appropriate care; new or spreading erythema, warmth, purulence, or odour; exposed bone/tendon or a probe-to-bone; rapidly advancing redness with pain out of proportion (see §08 — rule out necrotizing fasciitis); or deep purple intact skin. Verify staging definitions and management against your current local wound-care protocol and formulary — these vary by facility and jurisdiction.

Healing Capacity — Why Some Skin Cannot Repair

§ 05

Two patients with identical wounds heal at completely different rates — because healing is a whole-body capacity, not a property of the wound. The body must have the raw materials (nutrition), a delivery system (perfusion and oxygen), and an absence of ongoing injury (pressure, moisture, infection). When that capacity is low, the most advanced dressing on the market still cannot close the wound.

This reframes the central question from “What dressing should I use?” to “What is stopping this body from healing — and can I fix it?” A wound that has not improved in two to four weeks of appropriate care is almost never a dressing problem. It is a perfusion, nutrition, pressure, or undiagnosed-cause problem.

The Four Drivers of Healing

Nutrition • Perfusion & Oxygen • Pressure / Moisture Control • Mobility. Every rung of the Healing Ladder in §10 is an expression of these four. Optimise them and most wounds heal themselves.

Interactive Clinical Partner

Healing Capacity — Care Calibrator

Slide to estimate the patient’s overall capacity to heal from what you know: nutritional status, perfusion (pulses, glucose, smoking, anaemia), mobility, and moisture/continence control. The tool adjusts your recommended priorities in real time. This is a teaching aid — it never replaces a formal risk assessment (e.g., Braden) or clinical judgment.

5/10

Moderate capacity

0 · Minimal5 · Moderate10 · Robust

Care Priorities

Optimise the modifiable drivers and protect the wound while the body catches up.

Lower capacity → the dressing matters less and the body matters more. Fix nutrition, perfusion, and offloading first; a wound stalled for 2–4 weeks signals an unaddressed driver, not the wrong dressing.

Myth vs. Evidence. Wound care attracts more folklore than almost any field in nursing. None of the beliefs below come from bad intentions — they come from a system that rewards the visible dressing over the invisible cause. The evidence is consistent: healing is built from protein, perfusion, offloading, and glycaemic control. Treat the person, not the label — make the human whole, and the skin follows.

Common belief	What the evidence supports
“The right dressing will heal the wound.”	A dressing protects and optimises the local bed — it does not supply the protein, blood flow, or pressure relief that actually rebuild tissue. The international pressure-injury guideline and wound-bed-preparation evidence put nutrition, perfusion, and offloading first; the dressing supports that work.^[1]
“Nutrition is a side issue once the wound is dressed.”	Inadequate protein, energy, and fluid are among the most common reasons a wound stalls. Screening and correcting malnutrition is a core healing intervention, not an extra — involve a dietitian early (see Module 03 — Clinical Nutrition).^[6]
“A diabetic foot wound is a dressing problem.”	It is a perfusion, pressure (offloading), and glycaemic-control problem first. Uncontrolled glucose and arterial disease blunt healing and raise infection risk; the dressing is downstream of all three (see Module 10 — Diabetes & Endocrine).
“Pour antiseptic in and it will clean itself out.”	Cytotoxic agents (full-strength iodine, peroxide) can harm the very cells that heal. Gentle cleansing with saline or a non-cytotoxic cleanser, plus removing non-viable tissue, is what prepares the bed.
“Stalled wound? Change the dressing more often.”	A wound that has not improved in 2–4 weeks of appropriate care signals an unaddressed driver — perfusion, nutrition, pressure, or an undiagnosed cause. Re-examine the body, not the product shelf.

Said Diplomatically at the Bedside

None of this means a colleague who reaches for a dressing is wrong — the dressing is necessary, just not sufficient. The respectful reframe is additive, not corrective: “The dressing is doing its job; let’s make sure the body can do its part too — how are we doing on protein, hydration, turning, and glucose?” That keeps the team aligned and the focus on the human, not a turf debate.

The TIME Wound Assessment Framework

§ 06

TIME is the structured way to read a wound bed at every dressing change, so that wound-bed preparation is systematic rather than habitual. Walk the four letters in order — each one points to a specific, repeatable action. None of them require an exotic product; most require only a clinician willing to look closely.

T — Tissue

Tissue, Non-viable or Deficient

Identify what is in the bed: healthy granulation (beefy red), unhealthy slough (yellow), or necrotic eschar (black). Non-viable tissue feeds bacteria and blocks healing.

Act: Debride non-viable tissue (per scope/order) — unless it is stable dry eschar on an ischaemic limb.

I — Infection

Infection / Inflammation

Look for the signs of local infection — increasing pain, erythema, warmth, oedema, odour, and rising exudate. Distinguish normal inflammation from spreading infection.

Act: Cleanse, consider topical antimicrobials for local infection; systemic signs (fever, spreading redness) demand prescriber review.

M — Moisture

Moisture Balance

The bed should be moist, not wet, not dry. Too much exudate macerates the edges; too little desiccates the bed and stalls cell migration.

Act: Match the dressing to the exudate — absorptive for heavy, hydrating for dry. Protect the peri-wound skin.

E — Edge

Edge / Epithelialisation

The wound edge tells you whether it is healing. Advancing pink epithelium is good; rolled (epibole), undermined, or static edges signal a stalled wound.

Act: Re-assess the whole picture — a non-advancing edge means a driver (perfusion, nutrition, pressure, infection) is unaddressed.

Measure length × width × depth and track the trend over time
Probe for undermining and tunnelling, and chart by clock position
Photograph with consent and a measuring guide for objective tracking
Cleanse with normal saline or a non-cytotoxic wound cleanser
Re-assess the four healing drivers at every non-progressing visit
Protect the peri-wound skin with a barrier

Don’t

Pour cytotoxic agents (full-strength iodine, peroxide) into a clean bed
Leave the same dressing plan running on a stalled wound “to see”
Pack a wound so tightly it impairs perfusion to the bed
Debride dry, stable eschar before confirming the limb is perfused
Treat heavy exudate by changing more often instead of fixing the cause
Chart “dressing changed, tolerated well” with no bed description

Golden Rule

TIME is not a checklist you run past a wound. It is a conversation you have with it. The bed is telling you what the body needs — the clinician who reads it closely rarely needs the expensive dressing.

Prevention First: The SSKIN Bundle

§ 07

The overwhelming majority of pressure injuries are preventable. Prevention is cheaper, safer, and infinitely kinder than treatment — and it is the truest expression of attention. Run the SSKIN bundle on every at-risk patient, every shift.

Surface

Provide the right support surface — pressure-redistributing mattress or cushion matched to risk. The bed and chair are clinical equipment, not furniture.

Skin Inspection

Inspect skin head-to-toe at least each shift, especially bony prominences and under devices. Non-blanchable redness is a Stage 1 alarm — act, do not chart and move on.

Keep Moving

Reposition on an individualised schedule; offload heels entirely. Even small, frequent shifts of weight relieve the capillary-crushing pressure that kills tissue.

I & N

Incontinence & Nutrition

Manage moisture with prompt cleansing and a barrier; treat incontinence as a skin emergency. Screen nutrition and hydration — the tissue cannot rebuild without fuel.

Device-Related Injuries

Oxygen tubing, masks, catheters, casts, and cervical collars cause a large and rising share of pressure injuries — in patients of every age. Check the skin under every device. Pad, rotate, and reposition tubing. A wound under a mask is no less preventable than one over the sacrum.

Always Reassess

A new or worsening pressure injury is a sentinel event, not an inevitability. When one appears, ask what in the bundle failed: was the surface wrong, the turning skipped, the nutrition unaddressed, the device missed, the patient too unstable to reposition? Fix the system, not just the skin.

Dermatologic Red Flags That Kill

§ 08

Most skin complaints are benign. A handful are emergencies that look ordinary for a few critical hours and then become catastrophic. The skill is not memorising rashes — it is knowing which features mean stop everything and escalate now.

The cardinal rule of these emergencies: pain out of proportion to what you can see, rapid progression, and systemic illness (fever, tachycardia, confusion) are far more alarming than the appearance of the skin itself.

Necrotizing Fasciitis (Surgical Emergency)

Suspect when pain is wildly out of proportion to visible findings, the redness advances by the hour (mark and time it), the skin develops dusky/violaceous patches, blisters, crepitus, or anaesthesia, and the patient looks systemically toxic. A rising LRINEC-style picture (high CRP, WBC, low sodium) supports the suspicion^[3] — but a normal score never rules it out. This needs urgent surgical and prescriber review, not a dressing. Delay costs limbs and lives.

Cellulitis (Common — but Watch It)

Cellulitis is warm, tender, spreading erythema with a relatively gradual onset and proportionate pain, usually without systemic toxicity. It is treated medically. The danger is anchoring: a wound nurse who labels every red leg “cellulitis” will eventually miss the necrotizing case hiding inside one. Re-examine, mark the border, and escalate if it outpaces the antibiotics.

Stevens-Johnson Syndrome / Toxic Epidermal Necrolysis

SJS/TEN is a life-threatening drug reaction: painful skin, a positive Nikolsky sign (skin shears with light lateral pressure), mucosal involvement (mouth, eyes, genitals), and large sheets of detaching epidermis — like a deep burn from the inside out. Suspect it after a new medication. Stop the suspected drug, escalate immediately, and treat the patient like a burns patient. This is a medical emergency, not a rash.

Case Vignette

A patient develops rapidly spreading, exquisitely painful erythema over a single limb in the space of 12 hours. The pain is wildly out of proportion to the skin findings; the area turns dusky and violaceous with tense bullae; the patient is febrile and tachycardic, and crepitus is felt on palpation.

Resolution: Suspect necrotizing fasciitis — a surgical emergency. Do not delay for imaging. Obtain an urgent surgical consult, start broad-spectrum antibiotics, and resuscitate the patient. A LRINEC score may support the diagnosis, but it does not rule it out.

Red Flags — Escalate Now

Pain out of proportion to the exam.
Rapid spread, dusky skin, bullae, or crepitus.
Systemic toxicity — fever, tachycardia, hypotension.
Skin sloughing or mucosal involvement (SJS/TEN).
Deep purple but intact skin (deep-tissue injury).

These are surgical and dermatologic emergencies — escalate now.

The “Be Human” Protocol for Skin Care

§ 09

Wound care is one of the most intimate acts in clinical practice. It exposes the body, often in its most vulnerable places, frequently in patients who cannot move, speak for themselves, or refuse. The WestNet protocol treats every dressing change as an encounter with a person — not a procedure on a body part.

Consent: Explain before you uncover. Ask permission to look and to touch — every time, even with the non-verbal patient.
Cover: Drape everything you are not examining. Expose the smallest area for the shortest time. Warmth and privacy are clinical care.
Gentleness: Soak adherent dressings off, never rip. Pain during care is a finding, not a given — pre-medicate when needed.
Pace: Move at the patient’s tolerance, not the cart’s schedule. Narrate each step so nothing is a surprise.
Name: Use it. Speak to the person, not over them. Not “the sacral wound in 4B.”

What to Say — and What Not To. The principles above become real in the words you choose at the bedside. The phrasing below is a starting script for an exposed, anxious, or non-verbal patient and their family — adapt it to the person in front of you.

Say This

“I’m going to look at your skin now to keep it healthy — is that alright?”
“I’ll only uncover the small area I need, and cover you straight back up.”
“Tell me if anything hurts and I’ll stop — we go at your pace, not mine.”
“This is a pressure area we caught early; here’s what we’re doing about it.”
To family: “You know them best — what helps them feel comfortable during care?”
To a non-verbal patient: narrate each step — “I’m lifting the dressing now; this may feel cool.”

Don’t Say

“This is the worst bedsore I’ve seen” — alarming, and the patient hears every word.
“You let this happen by not turning” — blame stalls care and wounds dignity.
“Just relax, it’s nothing” — dismissing pain or fear breaks trust.
Talking over the patient to a colleague as if they aren’t there.
“The sacral wound in 4B” — reducing a person to a room and a hole.
Rushing or ripping a dressing to stay on the cart’s schedule.

For the Non-Verbal or Cognitively Impaired Patient

Absence of objection is not consent, and inability to speak is not absence of feeling. Watch the face, the breathing, and the body for distress; pause when you see it. The same trauma-informed gentleness taught in Module 07 protects a patient who cannot tell you that being uncovered frightens them — assume awareness, and earn trust with every touch.

WestNet Healing Ladder

§ 10

Rung 1

Observe the Whole Person

Inspect skin head-to-toe. Read the body, not just the wound. Identify who is at risk before any breakdown appears.

Rung 2

Relieve Pressure & Moisture

Offload, reposition, choose the right surface, manage incontinence. Stop the ongoing injury before anything else.

Rung 3

Feed & Perfuse the Tissue

Optimise nutrition, hydration, glucose, and circulation. The body cannot rebuild what it is not supplied to build.

Rung 4

Prepare the Wound Bed (TIME)

Debride non-viable tissue, control infection, balance moisture, support the edge. Cleanse gently, dress to the bed’s needs.

Rung 5

Reassess the Trend, Not the Snapshot

Measure and track. A wound stalled 2–4 weeks means a driver is unaddressed — escalate before changing the dressing again.

Escalate

Specialist & Red-Flag Response

Wound, ostomy, vascular, surgical, or dermatology referral. Any red flag — nec fasc, SJS/TEN, deteriorating limb — escalates immediately. Document fully.

Closure vs. Coverage

§ 11

A wound that is dressed is not the same as a wound that is healing. The surface-only reflex measures success by how clean the dressing looks on rounds — the wound is covered, so it is “managed.” WestNet measures whether the wound is smaller, shallower, and advancing at the edge over time. Coverage hides the problem; closure solves it. If the trend is flat, the dressing is not the answer — the body is asking for something the dressing cannot give.

When Prevention Fails: Composite Patterns

§ 12

The following patterns recur across North American wound-care admissions. This section presents a composite case drawn from recurring systemic failures — not any single patient, institution, or jurisdiction. The lesson is architectural, not individual.

Pattern: Dress the Wound, Ignore the Body

An immobile patient develops sacral redness. It is charted but not acted on. Repositioning is documented but not consistently delivered. The patient is eating almost nothing; no nutrition referral is made. Days later the redness is a Stage 3 ulcer. The response is an escalating series of premium dressings — while the patient remains malnourished, dehydrated, and turned only sporadically. The wound deepens. The dressing budget rises. The cause is never touched.

What Module 05 Teaches

Every safeguard in the chain fails when staff treat the surface and ignore the system. At Rung 1 of the Healing Ladder — observing the whole person — this injury should have been prevented entirely. Instead the default pathway spends heavily to cover a wound that consistent turning, a dietitian, and attention would have closed, or never allowed to open. Quiet dressings were mistaken for healing.

Pressure Injury Stager — Practise the Call

§ 13

Staging drives the plan. Select the features you actually observe at the wound — the tool returns the most likely stage and a management bundle in real time. It mirrors the NPIAP logic: the deepest tissue type visible determines the stage, and an obscured base means you cannot stage at all. This is a teaching aid; it never replaces a hands-on assessment by a qualified clinician.

—

Select features observed

Tick the features present at the wound to estimate the stage and management bundle.

How to Use It

Stage describes the deepest tissue you can see. If slough or eschar obscures the base, the wound is Unstageable until cleared. Persistent deep purple/maroon discolouration of intact skin is a Deep Tissue Injury, which can deteriorate rapidly. The tool guides the call; the bedside clinician makes it.

Cellulitis or Necrotizing Fasciitis? The Differentiator

§ 14

This is one of the highest-stakes calls in wound care. Cellulitis is common and treated medically; necrotizing fasciitis is a surgical emergency that can look like cellulitis for the first few hours, then take a limb or a life. Mark what you actually observe — the tool weighs the picture and flags the critical next step.

Points toward Cellulitis

Common • managed medically

Points toward Necrotizing Fasciitis

Surgical emergency • act now

CellulitisUnclearNec Fasc

Awaiting input

Mark the features you observe

Clinical Safety

If any hard red flag is present — pain out of proportion, rapid hourly progression, dusky skin or blisters, crepitus, anaesthesia, or systemic toxicity — treat it as necrotizing fasciitis and escalate for urgent surgical review regardless of the meter. A normal LRINEC-style picture never rules it out. This tool supports — never replaces — prescriber and surgical assessment.

Document This, Not That

§ 15

The words in the chart shape the care that follows. Vague, judgemental, or surface-only notes hide the cause and stall the wound. Objective, observation-first language drives the right action — and protects the patient’s dignity. Tap any card to flip the weak note into one that works, and see why it lands differently.

Why Language Matters

A chart that says “dressing changed, tolerated well” tells the next clinician nothing and lets a deteriorating wound hide in plain sight. A chart that records tissue type, size, exudate, edge, pain, and the drivers being addressed turns the note into a clinical tool — and keeps the focus on the human, not the hole.

Wound Types — A Differential Deep-Dive

§ 16

“Chronic wound” is not a diagnosis — it is a description. Before a single dressing is chosen, the clinician must answer the question the wound is really asking: what caused you, and what is keeping you open? A venous ulcer treated as arterial, or a pyoderma treated as pressure, will never close. The five great families below cover the overwhelming majority of wounds you will meet, and each one points to a different cause that must be fixed first.

Wound family	Typical location	Classic appearance	Cause to fix first
Pressure injury	Bony prominences — sacrum, heels, ischium, occiput, under devices	Over a bone; staged by depth; non-blanchable erythema to exposed bone	Unrelieved pressure / shear — offload (see §04, §07)
Venous leg ulcer	“Gaiter” area — medial lower leg above the ankle	Shallow, irregular, wet; haemosiderin staining, oedema, varicosities	Venous hypertension — compression (only if arterial flow adequate)
Arterial / ischaemic ulcer	Toes, foot, lateral malleolus, pressure points	“Punched-out,” dry, pale/necrotic base; cold limb, absent pulses, severe pain	Inadequate perfusion — restore blood flow; do NOT compress
Diabetic foot ulcer	Plantar surface, under metatarsal heads, toe tips	Round, callused rim, often painless (neuropathy); may probe deep	Pressure (offloading) + glucose + perfusion (see §18)
Skin tear	Forearms, hands, lower legs of fragile/elderly skin	Traumatic flap; epidermis separated from dermis; a known cause	Trauma + skin fragility — preserve the flap, protect the skin (see §19)

The Question Behind Every Wound

Two wounds can look identical and need opposite treatment. The lethal example: a venous ulcer is treated with compression and heals; an arterial ulcer treated with compression loses the limb. Always assess perfusion before you commit to a plan. The appearance tells you what it looks like; the cause tells you what to do.

Atypical Wounds — Think Again

If a wound does not fit a common family, heals abnormally, has rolled/violaceous “heaped” or undermined purple borders, or fails appropriate care, think beyond the usual: pyoderma gangrenosum (do not debride — it worsens), vasculitis, malignancy (a Marjolin ulcer in a chronic wound), or calciphylaxis. These need diagnosis, not another dressing — refer.

Interactive Clinical Partner

Wound-Type Identifier

Pick the features you actually observe. The tool leans toward the most consistent wound family and names the cause to address first. A teaching aid — it never replaces vascular assessment or clinician judgment.

Select the features you observe to identify the likely wound family.

Why This Matters

Naming the family is not academic — it changes the whole plan, the dressing, and whether compression is safe or catastrophic. A wound mislabelled is a cause untreated, and a cause untreated is a wound that will not close no matter how good the dressing.

Leg Ulcers: Venous, Arterial & Mixed

§ 17

The lower leg is where the most dangerous wound-care mistake in nursing happens: applying compression to a limb that cannot tolerate it. Venous and arterial ulcers can look superficially similar, yet their treatments are opposites. The whole-person discipline of this module — assess the cause before the dressing — is nowhere more literally life-and-limb than here.

Venous Ulcer

Venous hypertension • compression helps

Medial “gaiter” area above the ankle. Shallow, irregular border, wet/exudative bed. Surrounding skin shows haemosiderin (brown) staining, oedema, varicose veins, and lipodermatosclerosis. Pulses usually present; pain relieved by elevation. Cause: blood pools and pressure rises in the venous system.

Arterial Ulcer

Ischaemia • do NOT compress

Toes, foot, lateral malleolus, pressure points. “Punched-out,” well-defined, dry, pale or necrotic base, minimal exudate. Limb is cold, hairless, shiny; pulses weak/absent; pain is severe and worse with elevation, better hanging down. Cause: the artery cannot deliver blood.

The ABPI Rule — Verify Before You Compress

Compression is the cornerstone of venous-ulcer healing — and a limb-threatening error on an ischaemic leg. An ankle–brachial pressure index (ABPI) is checked before compression: a normal range supports full compression; a low value contraindicates it; a high value can be falsely elevated (calcified vessels in diabetes) and needs specialist interpretation. If you cannot confirm arterial flow is adequate, do not apply compression — refer. Verify ABPI thresholds and the compression formulary against your current local vascular protocol.

Mixed-Aetiology Ulcers

Many older patients have both venous and arterial disease. These “mixed” ulcers require specialist assessment to determine whether (and how much) reduced compression is safe. Never assume; never guess. When the picture is mixed or unclear, the safe default is no compression until a vascular clinician has weighed in.

Feature	Venous	Arterial
Site	Medial gaiter area	Toes, foot, lateral malleolus
Edge / base	Irregular, shallow, moist	Punched-out, deep, dry/necrotic
Exudate	Moderate–heavy	Minimal
Pulses	Usually present	Weak or absent
Pain	Better with elevation	Worse with elevation; eased hanging down
Surrounding skin	Haemosiderin staining, oedema, varicosities	Cold, pale, shiny, hairless
Compression	Cornerstone (if ABPI adequate)	Contraindicated — restore flow first

Diabetic Foot Ulcers & Offloading

§ 18

The diabetic foot ulcer is the clearest case in this module of a wound that is never a dressing problem. Three forces converge: neuropathy (the patient cannot feel the injury), ischaemia (perfusion is impaired), and unrelieved pressure (the patient keeps walking on it). Add elevated glucose blunting immunity and healing, and a small ulcer becomes an amputation. The dressing is the least of it; offloading, perfusion, and glycaemic control do the work (see Module 10 — Diabetes & Endocrine).

Driver I

Neuropathy

Loss of protective sensation means the patient feels no warning pain. They walk on a wound, a stone in the shoe, or an ill-fitting boot for days. Inspect the feet every visit — including between the toes and the sole — because the patient cannot.

Driver II

Ischaemia

Peripheral arterial disease starves the wound. Assess pulses and perfusion; a non-healing diabetic foot ulcer with poor flow needs urgent vascular review. Perfusion is a prerequisite for any plan — not an afterthought.

Driver III

Pressure / Offloading

Healing is impossible while the patient walks on the ulcer. Offloading — total-contact cast, removable walker, or specialist footwear — is the single most important intervention. A dressing under a weight-bearing foot is a dressing being crushed.

Driver IV

Glucose & Infection

High glucose impairs white cells and healing; the diabetic foot infects fast and quietly. “Probe to bone” raises osteomyelitis suspicion. Control glucose with the team and treat infection early and seriously.

The “Probe to Bone” Sign

If a sterile probe in the ulcer reaches bone, suspect osteomyelitis until proven otherwise — escalate for imaging and specialist review. A diabetic foot ulcer with spreading redness, swelling, odour, or systemic signs is a limb emergency, not a routine dressing change. The classic trap is the “painless” foot that looks calm while infection tracks deep — neuropathy hides the alarm.

Wagner & the Multidisciplinary Foot Team

Diabetic foot ulcers are commonly graded (e.g., the Wagner system, 0–5, by depth and the presence of infection or gangrene) to standardise communication and trigger the right referral. The strongest evidence in this field is for the team: podiatry, vascular, endocrine, wound care, and nursing acting together prevent amputations. The lone dressing change does not. Verify grading and referral pathways against your current local diabetic-foot protocol.

Inspect both feet, between toes and soles, at every contact
Offload aggressively — the wound cannot heal while walked on
Assess pulses/perfusion and escalate poor flow urgently
Debride callus and non-viable tissue (per scope) to see the true wound
Treat infection early; probe-to-bone raises osteomyelitis suspicion
Partner glucose control with the diabetes team

Don’t

Assume a painless foot is a safe foot — neuropathy masks danger
Rely on a dressing while the patient keeps weight-bearing on it
Soak diabetic feet or use harsh chemicals between the toes
Ignore a stone-in-shoe history or new callus — both precede ulcers
Delay vascular review on a cold, pulseless, non-healing foot
Chart “dressing changed” without describing depth, probe, and perfusion

Skin Tears & the Fragile-Skin Patient

§ 19

A skin tear is a traumatic wound caused by shear, friction, or blunt force that separates the epidermis from the dermis (a partial-thickness tear) or both layers from underlying tissue (a full-thickness tear). They are overwhelmingly a problem of fragile skin — the very old, the very young, the steroid-dependent, the dehydrated — and they are largely preventable. They are not pressure injuries and must not be staged as such.

ISTAP Classification (Skin Tears)

The International Skin Tear Advisory Panel groups skin tears by how much of the skin flap remains and can be re-approximated: Type 1 — no skin loss; the flap can be realigned to cover the wound. Type 2 — partial flap loss; the flap cannot fully cover the bed. Type 3 — total flap loss; the wound bed is fully exposed. Classifying guides the dressing and the prognosis; the goal in every type is to preserve viable tissue.

Managing the Flap

If a viable flap is present, the single most valuable action is to gently re-approximate it over the wound bed — it is the patient’s own best dressing. Irrigate, ease the flap back into place (a moistened cotton tip helps), and secure with a non-adherent, low-trauma dressing. Mark the dressing with an arrow showing the direction of removal so the next clinician peels toward the flap’s attached base, never lifting it off again.

Never Use Aggressive Adhesives

Standard adhesive tape on fragile skin causes the next tear when it is removed — a self-inflicted, iatrogenic wound. Use silicone or non-adherent contact layers and tubular/roll retention rather than tape directly on the skin. Removing a dressing should never create a new wound.

Prevention is the real treatment. Fragile-skin patients live one careless transfer away from the next tear. The prevention bundle is simple, cheap, and dignified — and it reflects the same attention-first philosophy as the SSKIN bundle in §07.

Moisturise

Twice-daily emollient on fragile limbs measurably reduces skin-tear incidence. Hydrated skin tears less. This is one of the highest-yield, lowest-cost interventions in the whole module.

Pad & Protect

Long sleeves, shin guards, padded bed rails and wheelchair leg-rests, and clearing sharp edges from the environment prevent the blunt knocks that tear thin skin.

Handle Gently

Use proper transfer technique and slide sheets; never drag a limb or grip fragile forearms. Shear during a transfer is the classic mechanism — lift, don’t drag.

Hydrate & Nourish

Systemic hydration and adequate protein make skin more resilient. The same nutrition that closes wounds also helps skin resist tearing in the first place.

Surgical Wounds & Dehiscence

§ 20

Most surgical wounds heal predictably by primary intention — clean edges held together by sutures, staples, glue, or strips, sealing within hours and epithelialising over days. The clinician’s job is to protect that closure, recognise when it is failing, and know the difference between normal healing and surgical-site infection (SSI) or dehiscence.

Healing pathway	What it means	Typical example
Primary intention	Edges approximated and closed; minimal tissue loss	Sutured surgical incision, clean laceration
Secondary intention	Left open to granulate and contract from the base up	Pressure injury, abscess cavity, dehisced wound
Tertiary (delayed primary)	Left open initially (e.g., for contamination), then closed later	Contaminated abdominal wound closed after a few days

Dehiscence & Evisceration

Dehiscence is partial or complete separation of a closed surgical wound — often heralded by a sudden gush of serosanguineous fluid and a “giving way” sensation reported by the patient. Evisceration — protrusion of viscera (e.g., bowel) through the wound — is a surgical emergency: cover the exposed organs with saline-moistened sterile gauze, keep the patient still and flat with knees flexed, keep them NPO, and call surgery now. Do not attempt to push anything back in.

Recognising Surgical-Site Infection (SSI)

Suspect SSI with increasing pain after the early post-op days, spreading erythema beyond the immediate incision, warmth, swelling, purulent drainage, wound breakdown, or new fever. The honest reading is timing: a little redness on day one is expected; increasing redness, pain, and drainage on day four is a warning. Escalate for prescriber review rather than simply re-dressing.

Protect the Closure

Keep the incision clean and dry for the initial sealing window per surgical orders; handle with clean/aseptic technique; do not disturb strips or glue prematurely; and teach the patient to support the wound (a pillow splint) when coughing or moving. Closure is fragile until the tissue catches up — the dressing buys time for biology, it does not replace it.

Moisture-Associated Skin Damage (MASD)

§ 21

Excess moisture destroys skin from the outside in — and it is constantly mistaken for a pressure injury, then mistreated. Moisture-associated skin damage (MASD) is inflammation and erosion of the skin from prolonged exposure to urine, stool, sweat, wound exudate, or fistula output. Distinguishing it from a Stage 2 pressure injury is one of the most common — and consequential — bedside calls in this module.

Feature	Moisture damage (MASD)	Pressure injury (Stage 2)
Location	Skin folds, peri-anal, peri-wound — wherever moisture sits	Over a bony prominence
Shape / edges	Diffuse, irregular, “blotchy,” ill-defined	More distinct; conforms to the bony point
Depth	Superficial erosion; rarely full-thickness alone	Partial-thickness loss with a defined bed
Cause	Moisture ± friction	Pressure / shear over a bone
First fix	Remove the moisture; barrier protect	Offload the pressure

The MASD Family

IAD (incontinence-associated dermatitis) — from urine/stool. ITD (intertriginous dermatitis) — trapped moisture and friction in skin folds. Peri-wound maceration — from excess exudate. Peristomal/peri-fistula MASD — from effluent. The cause differs but the principle is identical: the skin is wet for too long.

The Fix: Cleanse, Protect, Contain

Cleanse gently with a pH-balanced no-rinse cleanser — not harsh soap and a rough cloth. Protect with a barrier (cream, film, or paste) so the skin is shielded before the next episode. Contain the source — a continence plan, appropriate absorbent products, exudate-matched wound dressings, a well-fitted stoma appliance. Treating MASD with a “cream” while leaving the skin soaking is treating the surface and ignoring the cause — the same error this whole module is built to correct.

Why It Matters

Macerated, eroded skin is the perfect launch pad for a pressure injury and for infection — the two often co-exist. Moisture and pressure compound each other. Treat incontinence as a skin emergency, not a laundry problem: every hour of contact is more damage. Verify product choices against your facility skin-care formulary.

Dressing Selection Mastery

§ 22

The dressing is the smallest part of healing — but choosing it well still matters, because the wrong dressing actively stalls a wound (a dry dressing on a dry bed desiccates it; an absorbent one on a dry bed sticks and traps). The discipline is simple: match the dressing to the wound bed and the exudate, protect the peri-wound skin, and step down as the wound improves. Below is a working knowledge of the major families. None of this overrides your facility formulary.

Dressing family	Best for	Watch out for
Hydrocolloid	Light exudate; shallow Stage 2; promotes autolysis	Not for heavy exudate or infected wounds; can macerate edges
Hydrogel	Dry or sloughy beds; donates moisture; aids autolytic debridement	Will macerate a wet wound — wrong for heavy exudate
Foam	Moderate–heavy exudate; cushioning; many anatomical shapes	Too absorbent for a dry bed — can dry it out
Alginate	Heavy exudate; bleeding/packing cavities (very absorbent, gels)	Needs moisture to work — dries out and sticks on a dry wound
Hydrofiber	Heavy exudate; locks fluid vertically, protecting edges	Same caution as alginate on dry beds
Transparent film	Superficial wounds, securing other dressings, protecting at-risk skin	Non-absorbent — never on a moderately/heavily exuding wound
Antimicrobial (e.g., silver, iodine, PHMB)	Locally infected or high-bioburden wounds, short courses	Not routine; reassess and step down — not for clean granulating beds
Non-adherent contact layer	Fragile beds, skin tears, low-trauma cover under a secondary dressing	Needs a secondary dressing to manage exudate

The Moisture-Balance Compass

Everything above reduces to one idea from the “M” of TIME (§06): a dry bed needs moisture donated; a wet bed needs moisture absorbed; a balanced bed needs to be protected and left alone. Get the moisture wrong and even the most expensive product fails. Get it right and a simple dressing usually suffices.

Interactive Clinical Partner

Dressing Selector

Describe the bed in front of you. The selector suggests a dressing category and explains the reasoning — it is a teaching aid, not a product endorsement, and never overrides your facility formulary or a prescriber order.

Select the wound’s exudate level and bed characteristics for a suggested dressing category.

Safety

Dressing names and indications vary by manufacturer and by facility formulary, and infected wounds, ischaemic limbs, and atypical wounds change the rules. Verify every choice against your current local wound-care formulary and the prescriber’s plan. When a wound is not progressing, change the assessment — not just the product.

Debridement: Methods & Judgment

§ 23

Debridement is the removal of non-viable tissue — slough and necrotic eschar — that feeds bacteria, harbours biofilm, and physically blocks healing (the “T” of TIME, §06). It is one of the most powerful wound interventions and one of the most consequential to get wrong. The first decision is never how to debride; it is whether to debride at all.

The First Question: Should You Debride?

Do not debride stable, dry, intact eschar on an ischaemic or unperfused limb — that dry cover is the body’s natural protection, and removing it on a limb that cannot heal exposes a wound that will not close and may invite infection or amputation. Confirm perfusion first. Debridement is also contraindicated or specialist-only in pyoderma gangrenosum, in actively bleeding or anticoagulated patients (for sharp methods), and wherever it exceeds your scope of practice.

Method	How it works	Speed	Notes
Autolytic	The body’s own enzymes liquefy non-viable tissue under a moisture-retentive dressing	Slow	Gentle, selective, low pain; widely within nursing scope; needs a perfused wound
Enzymatic	A topical enzyme preparation digests non-viable tissue	Moderate	Selective; requires an order; follow product directions exactly
Mechanical	Physical removal — monofilament pads, irrigation, (historically) wet-to-dry	Moderate	Wet-to-dry gauze is non-selective and painful — largely outdated; prefer monofilament/irrigation
Sharp / surgical	Scalpel, scissors, or curette remove non-viable tissue	Fast	Most rapid; requires advanced competency/credentialing and often a prescriber; check scope
Biological (larval)	Sterile medical maggots selectively digest slough	Fast (selective)	Highly selective; specialist-initiated; useful when surgery is unsuitable

Interactive Clinical Partner

Debridement-Method Matcher

Describe the situation. The matcher suggests a reasonable method and flags when not to debride at all. A teaching aid only — method choice depends on scope, credentialing, perfusion, and a prescriber order.

Select the wound and patient features to see a suggested debridement approach.

Scope & Safety

Sharp/surgical debridement is an advanced skill restricted by jurisdiction and facility credentialing. Never exceed your scope; when in doubt, refer to a wound specialist. Always confirm perfusion before removing eschar, and verify against your current local protocol.

Biofilm & the Wound-Infection Continuum

§ 24

Every open wound carries bacteria — contamination is universal and not, by itself, infection. The clinically useful idea is a continuum: bacteria move from harmless presence to active tissue invasion along a spectrum, and the clinician’s task is to recognise where a wound sits and act proportionately. Over-treating contamination wastes antimicrobials and breeds resistance; under-treating invasion costs tissue.

ContaminationBacteria present, not multiplying. Normal. No action beyond good wound hygiene.

ColonisationBacteria multiplying, no host harm, healing on track. Still no antimicrobials.

Local infectionSubtle signs: stalled healing, friable granulation, new pain/odour, rising exudate. Consider topical antimicrobial + wound hygiene.

Spreading / systemicErythema beyond the wound, warmth, fever, tachycardia. Prescriber review; systemic antibiotics per protocol.

Subtle (Covert) vs. Overt Local Infection

Classic infection signs (heat, redness, swelling, pus) are overt. But chronic wounds often show covert signs first: a wound that simply stops progressing, bright-red friable granulation that bleeds easily, increasing or new odour, new wound pain, and pocketing or bridging at the base. A non-healing wound with no obvious pus may still be locally infected — read the subtle signs, not just the dramatic ones.

What Biofilm Is — and Why It Defeats Dressings

Biofilm is a community of bacteria that builds a protective self-made matrix, anchoring to the wound bed and shrugging off antibiotics and the immune system. It is invisible to the eye, reforms within hours of disruption, and is a leading reason chronic wounds stall despite “good” dressings. You cannot dressing your way through biofilm.

Wound Hygiene: Disrupt, Don’t Just Cover

The evidence-aligned response to biofilm is mechanical and repeated: cleanse the whole wound and peri-wound at every change, debride non-viable tissue to physically break up biofilm (see §23), refashion the edge, and dress — using a topical antimicrobial for a defined period when local infection is suspected, then stepping down. Because biofilm reforms fast, consistency beats potency. This is wound hygiene, not a one-time clean. Antibiotic and antiseptic choices must follow your local antimicrobial-stewardship and wound-care protocols.

Negative Pressure Wound Therapy (NPWT)

§ 25

Negative pressure wound therapy — “wound VAC” in common speech — applies controlled sub-atmospheric pressure to a sealed wound through a foam or gauze filler and an occlusive drape connected to a pump and canister. Used for the right wound, it is a powerful adjunct. Used for the wrong wound, it causes serious harm. It is an adjunct, never a substitute for treating the cause.

Mechanism

Removes Exudate

Continuously draws away excess fluid and infectious material, reducing oedema and keeping the bed balanced — especially useful in heavily exuding wounds.

Mechanism

Promotes Granulation

Mechanical micro-deformation of the bed stimulates perfusion and granulation tissue, and the suction draws the wound edges inward (macrostrain), helping contraction.

Use Case

Bridges to Closure

Helps prepare large, deep, or dehisced wounds for delayed closure, flaps, or grafts — and protects certain closed surgical incisions at high risk of breakdown.

Use Case

Reduces Dressing Frequency

A sealed system can stay in place for days, reducing disturbance of the bed and the burden of frequent changes — when the seal and the wound allow.

Absolute Cautions — Know Before You Apply

NPWT is contraindicated or hazardous with: untreated osteomyelitis or untreated wound infection; necrotic tissue with eschar still present (debride first); malignancy in the wound; exposed blood vessels, anastomoses, organs, or nerves (risk of catastrophic bleeding — a recognised cause of death); and unexplored fistulae. Bleeding is the most dangerous complication. If a patient on NPWT has frank blood in the canister or tubing, stop and escalate immediately. Application and settings are a prescriber/specialist decision per local protocol.

Nursing Vigilance During NPWT

Watch the seal (loss of vacuum stalls therapy and can macerate skin), the canister (volume and colour — frank blood is an emergency), the peri-wound skin under the drape, the foam count (every piece placed must be removed — document the count), and the patient’s pain and systemic signs. NPWT does not excuse neglecting nutrition, perfusion, and offloading — those still do the healing.

Burns — Depth, Extent & Initial Care

§ 26

Burns are a wound where the first minutes shape the outcome. Two questions drive everything: how deep is the burn (which governs healing and grafting) and how large is it as a percentage of total body surface area (TBSA, which governs fluids and transfer). The skin’s lost barrier means fluid loss, hypothermia, and infection are immediate threats — a large burn is a whole-body emergency, not a skin problem.

Depth	Layers involved	Appearance	Pain & healing
Superficial (1st degree)	Epidermis only	Red, dry, no blisters; blanches	Painful; heals in days, no scar (e.g., sunburn)
Superficial partial-thickness	Epidermis + upper dermis	Moist, pink/red, blisters; blanches	Very painful; heals in ~2–3 weeks, usually no graft
Deep partial-thickness	Epidermis + deeper dermis	Wet/waxy, red-and-white, sluggish or no blanch	Variable pain; slow; may need grafting
Full-thickness (3rd degree)	Entire dermis ± below	Leathery, white/charred/brown, dry; no blanch	Painless in the centre (nerves destroyed); needs grafting

Estimating Extent — the Rule of Nines (Adult)

For a rapid adult TBSA estimate, the body is divided into regions of roughly 9% (or multiples): head & neck 9%, each arm 9%, the front of the torso 18%, the back of the torso 18%, each leg 18%, and the perineum 1%. The patient’s own palm (with fingers, “palmar surface”) approximates ~1% and is handy for small or scattered burns. Children differ (proportionally larger heads) — use a paediatric chart. Estimate only partial- and full-thickness areas; superficial (red, non-blistered) burns are not counted in TBSA for fluid decisions.

Interactive Clinical Partner

Rule-of-Nines TBSA Estimator (Adult)

Tap the regions with partial- or full-thickness burns to estimate total body surface area involved. This is a rapid teaching estimate for adults — it does not replace a formal burn chart, paediatric adjustment, fluid calculation, or a burn-centre referral decision.

Select burned regions

Awaiting input

Tap the body regions affected by partial- or full-thickness burns.

Adult Rule of Nines only. Use a paediatric chart for children. Estimate guides urgency and transfer thinking; fluid resuscitation and referral criteria follow your current local burn protocol.

Initial Burn Care & When to Refer

Stop the burning (cool running water for a sustained period, never ice), remove non-adherent hot clothing and jewellery, cover with a clean non-adherent layer, keep the patient warm, and manage pain. Escalate / consider burn-centre referral for: large TBSA; any full-thickness burn; burns to the face, hands, feet, genitals, or over joints; circumferential burns; electrical, chemical, or inhalation injury; and burns in the very young, very old, or medically frail. Airway first if there is any inhalation concern. Verify fluid formulas and referral thresholds against your current local protocol — this module does not specify volumes.

Common Dermatoses & Rashes

§ 27

Most rashes are not emergencies (those live in §08), but the bedside clinician is often the first to see them and the first asked “what is this?” A working vocabulary helps you describe a lesion accurately, recognise the common benign patterns, and — most importantly — know when something ordinary-looking deserves a closer look. The discipline is the same as the rest of this module: describe what you see objectively before you label it.

Describe Before You Diagnose — Morphology Vocabulary

Macule — flat, <1cm colour change. Patch — flat, >1cm. Papule — raised, <1cm. Plaque — raised, flat-topped, >1cm. Vesicle — small fluid blister. Bulla — large fluid blister. Pustule — pus-filled. Wheal — transient raised oedematous (hives). Nodule — deeper, solid. Note distribution, colour, whether it blanches, and whether mucosa is involved — a clear description travels better than a guessed diagnosis.

A bedside atlas. Tap each card to turn the everyday presentation into the key recognition feature and the practical action. These are common, generally non-emergent patterns — but each card notes the line at which it stops being routine.

A Blanch Test That Cannot Wait

One rash rule overrides everything in this section: a non-blanching rash (petechiae/purpura that stays visible when pressed — the “glass test”) in an unwell, especially febrile, patient may signal meningococcal sepsis or another life-threat. That is not a dermatosis — it is an emergency. Escalate immediately. When in doubt about any rash, describe it precisely and ask for review rather than guessing.

Skin Cancer & the ABCDE Rule

§ 28

Clinicians who undress patients for wound and skin care are in the single best position in the health system to catch a skin cancer early — often on skin the patient cannot see (the back, the scalp, the soles). You are not expected to diagnose; you are expected to notice and refer. The most dangerous common skin cancer, melanoma, is highly curable when caught early and lethal when missed. A few seconds of attention during routine care saves lives.

The Three You Should Recognise

Basal cell carcinoma (BCC) — the most common; a pearly, translucent papule with fine surface vessels, often on sun-exposed skin; may ulcerate (“rodent ulcer”) and rarely spreads but grows locally. Squamous cell carcinoma (SCC) — a scaly, crusted, or ulcerated firm lesion on sun-damaged skin; can metastasise. Melanoma — the deadliest; arises in a new or changing pigmented lesion. Any non-healing “wound” that will not close, especially on sun-exposed skin, may be a skin cancer — a Marjolin ulcer can also arise in a chronic wound or scar. Refer rather than re-dress.

The ABCDE rule for pigmented lesions. A practical screen for which moles deserve a closer professional look. Tick the features you observe on a pigmented lesion — the tool tallies the warning signs and frames the next step. It does not diagnose; concerning lesions need a clinician’s assessment.

Select observed features

Tick the ABCDE features present on the pigmented lesion.

The “E” Is the Most Important Letter

Evolution — any change over time — is the strongest single warning sign, even when A–D look reassuring. A lesion that is new, growing, changing colour or shape, itching, bleeding, or simply “different from the others” (the ugly-duckling sign) warrants referral. Also escalate any pigmented lesion that bleeds or ulcerates without trauma. When in doubt, photograph (with consent) and refer — never shave, freeze, or “treat” a suspicious pigmented lesion yourself.

Nutrition for Wound Healing

§ 29

Of the four pillars (§03), nutrition is the one most often acknowledged and least often acted on. A wound is a construction site, and construction needs materials: a malnourished body literally cannot manufacture the collagen, immune cells, and new tissue that close a wound. Screening and correcting nutrition is not an adjunct to wound care — it is wound care, and it belongs in the plan from day one (see Module 03 — Clinical Nutrition).^[6]

Building block	Role in healing	Practical note
Protein	The raw material for collagen, granulation, and immune cells; demand rises with a wound	The most important macronutrient for healing; deficiency stalls wounds. Involve a dietitian for targets.
Energy (calories)	Fuels the whole repair process; without it, the body burns protein for energy instead of building tissue	Adequate non-protein calories “spare” protein for healing.
Fluid / hydration	Maintains perfusion to the wound bed and skin turgor	Often the simplest deficit to miss and to fix; dehydration impairs delivery.
Vitamin C	Essential cofactor for collagen cross-linking and capillary integrity	Deficiency impairs collagen; correct a documented deficiency — do not megadose blindly.
Zinc	Cofactor in protein synthesis, cell proliferation, and immune function	Supplement a documented deficiency only; excess impairs healing and copper status.
Vitamin A, iron, copper	Support epithelialisation, oxygen delivery, and collagen	Address as part of overall status; iron supports the perfusion/oxygen pillar.

No Blind Megadosing

This module specifies no doses. Routinely flooding patients with high-dose vitamin C or zinc “to heal a wound” is not evidence-based, can cause harm (zinc excess impairs copper and immune function), and substitutes a supplement for the real work of feeding the patient. Correct documented deficiencies, optimise overall protein and energy, and let a dietitian set targets. Verify any supplementation against your current local protocol and the dietitian’s plan.

Food First — the WestNet Reflex

Reach for real food and fluid before reaching for the supplement shelf. Screen every at-risk and wounded patient for malnutrition (a validated tool, per facility policy), make eating possible and dignified (positioning, assistance, dentures, preferences, time), fortify meals, and bring in a dietitian early. The body that is fed heals the wound; the most expensive dressing on a starving patient still fails. Make the human whole, and the skin follows.

The Honest Reframe at the Bedside

When a colleague is reaching for another premium dressing on a stalled wound, the additive, non-corrective question is simple and diplomatic: “The dressing’s fine — are we sure this patient is actually eating and drinking enough to build new tissue? Should we get a nutrition screen and the dietitian in?” It keeps the team aligned and moves the focus to the cause.

Offloading, Positioning & Support Surfaces

§ 30

Pressure is the cause; offloading is the cure. No dressing, nutrient, or antimicrobial can heal tissue that is being crushed against bone hour after hour. This section turns the “Keep moving” and “Surface” elements of SSKIN (§07) into concrete bedside practice — the mechanical work that prevents most pressure injuries and is non-negotiable for healing the ones that occur.

Why Pressure Kills Tissue

Capillaries are crushed when external pressure exceeds the pressure inside them, cutting off oxygen and nutrients to the tissue between skin and bone. Shear (skin dragged one way while deeper tissue stays) and friction compound the damage. The danger is a product of pressure × time: high pressure for a short time, or modest pressure for a long time, both kill tissue. Relieving the load — even briefly, even often — is what lets blood back in.

Reposition on a Schedule

Turn and reposition at-risk patients on an individualised schedule, and encourage small frequent weight shifts in chairs. The schedule is documented and delivered, not just charted — a turn written but not done heals nothing.

Float the Heels

The heel has almost no padding over bone. Float it off the surface entirely with a pillow under the calf (not under the heel), or a heel-offloading device. Heels are second only to the sacrum for pressure injuries.

The 30° Tilt

A 30-degree side-lying tilt (and limiting head-of-bed elevation, which drives sacral shear) keeps weight off the bony trochanter and sacrum better than lying directly on the hip. Position with pillows to hold the angle.

Match the Surface to Risk

Choose the support surface for the patient’s risk — from a pressure-redistributing foam mattress to powered alternating-pressure or low-air-loss systems for high risk. The bed and cushion are clinical equipment; reassess as risk changes.

A Surface Is Not a Substitute for Turning

The most advanced mattress does not replace repositioning — it buys margin, it does not abolish the need to move the patient. Equally, seated patients are at high risk: time in a chair concentrates pressure on the ischium and needs its own offloading and weight-shift plan. Reassess offloading whenever the patient’s mobility, weight, or medical stability changes. Verify repositioning frequency and surface selection against your current local protocol.

Offloading Is Attention Made Physical

Every theme of this module converges here: the most reliable pressure-injury prevention “device” is a clinician who returns, looks, and moves the patient — gently, with consent, on the patient’s schedule. Offloading is the four pillars and the “Be Human” protocol (§09) expressed as hands on a patient at the bedside.

Scenario Quiz — Apply the Module

§ 31

Eight applied, single-best-answer scenarios that draw the deep-dive sections together. Pick an answer to see whether it is correct and why — the reasoning matters more than the score. This is formative self-check practice; it is separate from the graded Competency Assessment in §33.

Use It to Learn, Not Just to Score

If an answer surprises you, return to the section it draws from and re-read the reasoning. Every scenario here reflects a real decision point from this module — perfusion before compression, offloading before dressings, cause before cover. Verify all clinical decisions against your current local protocols.

References & Evidence Base

§ 32

The clinical guidance in this module is drawn from peer-reviewed literature indexed by the U.S. National Library of Medicine (PubMed / PMC) and from current clinical-practice guidelines published by major wound-care and infectious-disease bodies. Each citation below links to its source — journal articles to a PubMed title search, guideline bodies to their official publication.

European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Injury Advisory Panel (NPIAP), Pan Pacific Pressure Injury Alliance (PPPIA). Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. 3rd ed. 2019.International Guideline • internationalguideline.com
Edsberg LE, Black JM, Goldberg M, et al. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System. Journal of Wound, Ostomy and Continence Nursing. 2016.Peer-reviewed • PubMed (NLM)
Wong CH, Khin LW, Heng KS, et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Critical Care Medicine. 2004.Peer-reviewed • PubMed (NLM)
Stevens DL, Bisno AL, Chambers HF, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections (IDSA). Clinical Infectious Diseases. 2014.IDSA Guideline • PubMed (NLM)
U.S. National Library of Medicine. MedlinePlus / StatPearls (NCBI Bookshelf) — Pressure Injury; Cellulitis. National Center for Biotechnology Information.NCBI Bookshelf • nlm.nih.gov
Munoz N, Posthauer ME, Cereda E, et al. The Role of Nutrition for Pressure Injury Prevention and Healing: The 2019 International Clinical Practice Guideline Recommendations. Advances in Skin & Wound Care. 2020.Peer-reviewed • PubMed (NLM)
Gould L, Abadir P, Brem H, et al. Chronic Wound Repair and Healing in Older Adults: Current Status and Future Research (NIH/NIA Wound Healing Workshop). Journal of the American Geriatrics Society / Wound Repair and Regeneration. 2015.NIH-convened • PubMed (NLM)

On the Evidence Base

Staging definitions follow NPIAP/EPUAP; prevention reflects the international pressure-injury guideline; the cellulitis-vs-necrotizing-fasciitis logic draws on the IDSA skin-and-soft-tissue guideline and the LRINEC literature. These sources inform — but never replace — facility policy, physician orders, and jurisdictional scope of practice.

Competency Assessment

§ 33

Ten questions. Pass threshold: 7/10 for CE credit (upon accreditation approval).

Why does WestNet describe skin breakdown as a “downstream signal” rather than a local skin problem?

Name the six NPIAP pressure injury categories and the single feature that distinguishes Stage 4 from Stage 3.

A wound base is fully obscured by yellow slough. What stage is it, and why can you not assign a number?

What do the four letters of TIME stand for, and what action does each prompt?

List the four drivers of wound healing. Which is most often missed in a stalled wound?

Name three features that should make you suspect necrotizing fasciitis over simple cellulitis.

What does the SSKIN bundle stand for, and why is device-related skin checked under each device?

A patient develops painful skin and a positive Nikolsky sign after a new medication. What do you suspect and do?

Why is a stable, dry eschar on an ischaemic heel sometimes left intact rather than debrided?

Q10

What is the difference between a covered wound and a healing wound, and how do you tell them apart?

Accreditation & Faculty

§ 34

Accreditor	Status
ANCC (American Nurses Credentialing Center)	Application pending
ACCME (Accreditation Council for Continuing Medical Education)	Application pending
CARNA (College of Registered Nurses of Alberta)	Application pending
CPSA (College of Physicians & Surgeons of Alberta)	Planned

Course Director: WestNet Medical Clinical Education Division
Publication: WestNet Medical Publications • WestNet Catalog 731985456604 • ISBN 978-0-XXXXX-XXX-X (Pending)
Platform: WestNet Unified Health Platform / HealthOS v3.6

Glossary

Ref

Blanchable erythema	Redness that whitens under light pressure and returns — intact microcirculation. Non-blanchable erythema (stays red) signals a Stage 1 pressure injury.
Debridement	Removal of non-viable (slough/necrotic) tissue to prepare the wound bed. Avoided on stable dry eschar over an unperfused limb.
Deep Tissue Injury (DTI)	Persistent deep red, maroon, or purple discolouration of intact or non-intact skin from pressure/shear damage to underlying tissue; can deteriorate rapidly.
Eschar	Black/brown necrotic tissue covering a wound. When it obscures the base, the wound is Unstageable.
HealthOS	WestNet’s unified clinical platform for ER, inpatient, pharmacy, labs, wound care, and dermatology across Canada and the USA.
Iatrogenic	Harm caused by medical care itself — including device-related pressure injuries and drug-induced SJS/TEN.
LRINEC	Laboratory Risk Indicator for Necrotizing Fasciitis — a lab-based score (CRP, WBC, sodium, etc.) that raises suspicion. Supportive only; a normal score never excludes the diagnosis.
Maceration	Softening and breakdown of skin from prolonged moisture; whitened, waterlogged peri-wound skin signals excess exudate or incontinence.
Nikolsky sign	Epidermis shears off with light lateral pressure — a red flag for SJS/TEN and other blistering emergencies.
NPIAP	National Pressure Injury Advisory Panel — the body whose staging definitions are used throughout this module.
Perfusion	Delivery of oxygenated blood to tissue. Inadequate perfusion (PAD, hypotension, anaemia) is a leading cause of non-healing wounds.
SSKIN	Surface, Skin inspection, Keep moving, Incontinence/moisture, Nutrition — the pressure-injury prevention bundle in §07.
TIME	Tissue, Infection/inflammation, Moisture balance, Edge — the structured wound-bed assessment framework in §06.
Unstageable	Full-thickness pressure injury whose base is obscured by slough or eschar; depth (and therefore stage) cannot be determined until cleared.

Related WestNet Medical Modules

This module is part of a 12-title series. See also: Module 03 — Clinical Nutrition, Module 07 — De-escalation & Trauma-Informed Care, and Module 10 — Diabetes & Endocrine.

Wound Care &Skin Integrity

Continuing Education Information

Program Preface

Skin Is Never “Just Skin”

The Four Pillars of WestNet Skin Integrity

Nutrition

Perfusion & Oxygen

Pressure, Moisture & Mobility

Attention & Dignity

Pressure Injury Staging

Healing Capacity — Why Some Skin Cannot Repair

The TIME Wound Assessment Framework

Tissue, Non-viable or Deficient

Infection / Inflammation

Moisture Balance

Edge / Epithelialisation

Prevention First: The SSKIN Bundle

Surface

Skin Inspection

Keep Moving

Incontinence & Nutrition

Dermatologic Red Flags That Kill

The “Be Human” Protocol for Skin Care

WestNet Healing Ladder

Closure vs. Coverage

When Prevention Fails: Composite Patterns

Pressure Injury Stager — Practise the Call

Cellulitis or Necrotizing Fasciitis? The Differentiator

Points toward Cellulitis

Points toward Necrotizing Fasciitis

Document This, Not That

Wound Types — A Differential Deep-Dive

Leg Ulcers: Venous, Arterial & Mixed

Venous Ulcer

Arterial Ulcer

Diabetic Foot Ulcers & Offloading

Neuropathy

Ischaemia

Pressure / Offloading

Glucose & Infection

Skin Tears & the Fragile-Skin Patient

Moisturise

Pad & Protect

Handle Gently

Hydrate & Nourish

Surgical Wounds & Dehiscence

Moisture-Associated Skin Damage (MASD)

Dressing Selection Mastery

Debridement: Methods & Judgment

Biofilm & the Wound-Infection Continuum

Negative Pressure Wound Therapy (NPWT)

Removes Exudate

Promotes Granulation

Bridges to Closure

Reduces Dressing Frequency

Burns — Depth, Extent & Initial Care

Common Dermatoses & Rashes

Skin Cancer & the ABCDE Rule

Nutrition for Wound Healing

Offloading, Positioning & Support Surfaces

Reposition on a Schedule

Float the Heels

The 30° Tilt

Match the Surface to Risk

Scenario Quiz — Apply the Module

References & Evidence Base

Competency Assessment

Accreditation & Faculty

Glossary

Wound Care &
Skin Integrity