How should a Stage II pressure injury with surrounding erythema and central granulation tissue nodules be described?

Stage II Pressure Injury with Surrounding Erythema and Central Granulation Tissue

This wound should be documented as a Stage II pressure injury with partial-thickness skin loss presenting as a shallow open ulcer with a red-pink wound bed, accompanied by surrounding erythema and friable granulation tissue nodules centrally, which raises concern for local infection or biofilm formation requiring immediate wound assessment and management. 1

Accurate Staging Documentation

• Stage II pressure injuries are defined as partial-thickness loss of dermis presenting as a shallow open ulcer with a viable red-pink wound bed without slough. 1
• The wound bed should appear as a shallow crater or open ulcer with visible dermal tissue but no exposure of deeper structures such as subcutaneous fat, fascia, muscle, or bone. 2
• Document the anatomic location (e.g., sacral, ischial, trochanteric), wound dimensions in centimeters (length, width, depth), and characteristics of the wound bed and surrounding tissue. 3

Describing the Central Nodular Tissue

• The "ripe of nodules" you describe centrally is most likely friable granulation tissue, which appears as red, raised nodular tissue in the wound bed. 1
• Friable or poor-quality granulation tissue that bleeds easily with minimal contact is a clinical indicator of local wound infection or biofilm presence and should be documented as such. 1
• Normal healthy granulation tissue appears as beefy red, moist tissue that does not bleed spontaneously, whereas friable granulation suggests underlying bacterial burden exceeding 10^4 CFU/g. 1

Assessing the Surrounding Erythema

• Surrounding erythema (redness) extending beyond the wound margins indicates inflammation and is a key clinical sign of local infection, particularly when accompanied by increased warmth, induration, or increased pain. 1
• Low-level chronic erythema with delayed healing despite adequate wound care is a specific indicator of biofilm formation, which occurs in 80-90% of chronic wounds. 1
• Document whether the erythema is blanchable or non-blanchable, its extent in centimeters from the wound edge, and whether it is accompanied by warmth, edema, or induration. 3

Critical Assessment for Infection

You must determine whether this wound has local infection versus simple colonization, as this fundamentally changes management:

• Suspect local infection when you observe: increasing wound size, friable granulation tissue, increased exudate, surrounding erythema/warmth, increased pain out of proportion to baseline, or malodor. 1
• The combination of friable central granulation nodules and surrounding erythema strongly suggests local infection requiring wound cultures (using Levine technique if tissue biopsy unavailable) and potential antimicrobial therapy. 1
• Do not obtain wound cultures routinely—only when infection is clinically suspected, as all pressure injuries are colonized with bacteria. 4

Biofilm Consideration

• Failure of wound healing despite adequate wound care, combined with low-level chronic erythema and friable granulation, indicates probable biofilm formation. 1
• Biofilms develop within 10 hours of wound contamination and are present in 80-90% of chronic wounds, creating persistent inflammation that impedes healing. 1
• Management requires biofilm-based wound care including tissue debridement to remove biofilm, topical antimicrobials (iodine, medical-grade honey, silver, EDTA), and pH management targeting 4-6. 1

Complete Documentation Template

Document as follows: "Stage II pressure injury [anatomic location] measuring [length] x [width] x [depth] cm, with partial-thickness dermal loss presenting as shallow open ulcer. Wound bed contains friable red granulation tissue with nodular appearance centrally. Surrounding skin demonstrates erythema extending [measurement] cm from wound margins, with [warmth/induration/edema if present]. Clinical signs suggest local infection/biofilm formation. [Exudate characteristics]. [Pain level]." 1, 3

Common Pitfalls to Avoid

• Do not confuse moisture-associated skin damage (maceration from incontinence) with Stage II pressure injury—true Stage II results from pressure/shear, not moisture alone. 5
• Do not stage the wound higher than Stage II unless you can visualize subcutaneous fat or deeper structures—the presence of granulation tissue alone does not make it Stage III. 1, 2
• Do not ignore the clinical signs of infection (friable granulation, surrounding erythema)—these require intervention beyond standard wound care. 1
• Do not assume the nodular tissue is normal healing granulation—friable, easily bleeding granulation indicates pathology requiring treatment. 1