How do I describe a Stage 2 pressure injury with peripheral erythema and a central nodular area when there are no systemic signs of infection?

Documentation of Stage 2 Pressure Injury with Periwound Erythema and Central Nodular Tissue

Document this wound as "Stage 2 pressure injury with periwound erythema and central nodular tissue; clinical infection present without systemic signs" and classify the infection severity as PEDIS Grade 2 (Mild) based on the presence of local inflammatory signs confined to skin and subcutaneous tissue. 1

Wound Staging and Description

Stage 2 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 Your description should include:

• Location: Specify the anatomical site (sacral, ischial, trochanteric, or other bony prominence) 1
• Size: Measure and document length × width in centimeters, and depth in millimeters 1
• Wound bed characteristics: Note the "nodular" central tissue—describe its color, consistency, and whether it represents granulation tissue, slough, or other tissue type 2
• Periwound erythema: Measure the extent of erythema from the wound edge in centimeters 1
• Exudate: Document type (serous, serosanguineous, purulent), amount, and odor 2

Infection Classification Without Systemic Signs

This wound meets criteria for local infection (PEDIS Grade 2/Mild) because it demonstrates ≥2 signs of inflammation: erythema, local swelling or induration, local tenderness or pain, local warmth, or purulent discharge. 1 The key distinguishing features are:

• Erythema measuring 0.5-2 cm from wound edge indicates mild infection involving only skin and subcutaneous tissue 1
• Absence of systemic inflammatory response signs (temperature <38°C, heart rate <90 bpm, respiratory rate <20 breaths/min, WBC <12,000 cells/µL) confirms this is not a moderate or severe infection 1
• No involvement of deeper structures (no exposed bone, tendon, muscle, or evidence of abscess, osteomyelitis, septic arthritis, or fasciitis) 1

Critical Differential Considerations

Exclude other causes of inflammatory response before attributing erythema to infection: trauma, gout, acute Charcot neuro-osteoarthropathy, fracture, thrombosis, or venous stasis can mimic infection. 1

The central nodular tissue requires careful characterization to distinguish between:

• Granulation tissue (healthy red-pink, granular appearance indicating healing) 2
• Hypergranulation tissue (overgrowth of granulation tissue above wound edges) 3
• Slough (yellow, tan, or white devitalized tissue that would make the wound "unstageable" until removed) 1, 4
• Biofilm (translucent to opaque coating that appears shiny or slimy and impedes healing) 1

Documentation Template

Your documentation should follow this structure:

"Stage 2 pressure injury, [location], measuring [length] × [width] cm with [depth] mm depth. Wound bed demonstrates [describe nodular tissue characteristics]. Periwound erythema extends [measurement] cm from wound edge. [Describe exudate]. Local infection present (PEDIS Grade 2/Mild) with [list ≥2 inflammatory signs present]. No systemic signs of infection. No exposed deeper structures." 1

Management Implications of This Classification

Mild local infection (PEDIS Grade 2) without systemic signs requires:

• Local wound care with appropriate dressing selection based on exudate level and wound characteristics 2, 3
• Wound cleansing with normal saline at each dressing change 2
• Consider topical antibiotics only if no improvement in healing after 14 days of appropriate wound care 2
• Systemic antibiotics are NOT indicated unless the patient develops systemic signs, erythema >2 cm, or involvement of deeper structures 1, 2

Common Pitfalls to Avoid

Do not stage the wound as Stage 3 or higher unless there is full-thickness tissue loss exposing subcutaneous fat, muscle, tendon, or bone—periwound erythema and nodular tissue in the wound bed do not automatically upgrade the stage. 1, 5

Do not confuse moisture-associated skin damage or friction injury with pressure injury—Stage 2 pressure injuries specifically result from pressure and/or shear over bony prominences, not from maceration or friction alone. 6, 5

Do not assume all erythema represents infection—measure the extent carefully and document whether it is blanchable (normal inflammatory response) or non-blanchable (Stage 1 pressure injury or deep tissue injury). 1, 6

Monitor for biofilm presence if the wound fails to heal despite appropriate care—80-90% of chronic wounds are colonized by biofilm, which creates a barrier to healing and requires specific management strategies including debridement. 1