How do I document a Stage II pressure injury with a central 0.5 cm raised nodule, pink intact periwound skin, and no systemic infection in a type 2 diabetic patient (HbA1c 7.2 %) who is ambulating with assistance and has no recent corticosteroid use?

Documentation of Stage II Pressure Injury with Central Nodule

Document this wound as a Stage II pressure injury with atypical features requiring urgent evaluation for malignancy, infection, and vascular compromise—the presence of a raised central nodule in a diabetic patient mandates immediate biopsy consideration because lesions appearing as diabetic foot ulcers may occasionally be malignancies such as melanoma or Kaposi sarcoma. 1

Immediate Documentation Requirements

Wound Classification and Baseline Measurements

• Record the wound as "Stage II pressure injury" with precise anatomical location (e.g., sacral, heel, ischial) 2
• Measure and document length, width, and depth in centimeters at this visit and at every subsequent encounter to distinguish true healing from expansion 3, 2
• Describe the central nodule specifically: measure its diameter (0.5 cm), height above wound bed, color, consistency (firm vs. soft), and whether it is fixed to underlying structures 4
• Document periwound skin as "pink, intact, without erythema, warmth, or induration" to establish baseline for infection monitoring 3

Critical Atypical Feature Assessment

The raised central nodule is an atypical finding that requires explicit documentation and urgent action. 1 While you state no systemic infection is present, this nodule pattern demands:

• Immediate consideration of biopsy for any recalcitrant or atypical wound, as lesions appearing to be diabetic foot ulcers may be malignancies 1
• Document whether the nodule is friable, has abnormal granulation tissue, or exhibits unusual color (these are secondary signs suggesting either infection or malignancy) 1
• Record the patient's diabetes control (HbA1c 7.2%) and mobility status (ambulating with assistance) as these directly impact healing prognosis 5

Infection Status Documentation

Clinical Signs Assessment

Even without systemic infection, document the presence or absence of all inflammatory signs:

• Erythema extent: "No erythema beyond wound margins" or measure any present in centimeters 1
• Warmth: "Periwound temperature equal to surrounding skin" 1
• Tenderness/pain: Document patient's pain score and whether tenderness is present on palpation 1
• Induration: "No induration palpable" 1
• Drainage: "No purulent or non-purulent drainage present" 1, 3

Infection must be diagnosed clinically based on at least 2 classic signs of inflammation or purulent secretions—document explicitly that fewer than 2 signs are present to justify "no infection" classification. 1, 5

Vascular Assessment Documentation

Do not rely solely on clinical examination; up to 50% of diabetic foot ulcer patients have peripheral arterial disease despite palpable pulses. 3

• Palpate and document dorsalis pedis and posterior tibial pulses bilaterally (present/diminished/absent) 3
• Record ankle-brachial index (ABI) if available—values <0.9 indicate PAD, <0.6 significant ischemia, <0.5 critical limb ischemia 1, 3
• Document capillary refill time, skin temperature, and dependent rubor or pallor on elevation 3
• If ABI >1.3 (calcified vessels common in diabetes), document need for toe-brachial index or duplex ultrasound 3

Neuropathy Assessment

• Test and document protective sensation using 10-g monofilament at multiple foot sites 3, 5
• Record whether patient can feel the nodule or wound (loss of sensation present in 78% of diabetic foot ulcers) 3

Wound Bed and Surrounding Tissue

• Describe wound bed composition: percentage of granulation tissue, slough, necrotic tissue, or exposed deeper structures 3
• Document whether probe-to-bone test is positive (critical for osteomyelitis assessment in diabetic wounds) 5
• Record any undermining or tunneling with measurements 1

Pressure Relief Documentation

• Document current off-loading strategy (e.g., heel protector, pressure-redistributing mattress, repositioning schedule) 1
• Note patient's mobility limitations (ambulating with assistance) and how this affects pressure relief 3

Recommended Documentation Template

"Stage II pressure injury, [location], measuring [length] × [width] × [depth] cm. Central raised nodule 0.5 cm diameter, [color], [consistency]. Periwound skin pink, intact, without erythema (0 cm), warmth, tenderness, or induration. No purulent or non-purulent drainage. Dorsalis pedis pulse [present/absent], posterior tibial pulse [present/absent]. Capillary refill [time]. 10-g monofilament sensation [intact/absent]. Probe-to-bone test [positive/negative]. Patient ambulating with assistance. HbA1c 7.2%. No systemic signs of infection (afebrile, normal WBC). Atypical central nodule warrants biopsy consideration to exclude malignancy. Plan: [specific interventions]." 1, 3, 4

Critical Next Steps

• Obtain plain radiographs within 24 hours to evaluate for underlying osteomyelitis given diabetic status 5
• Consider urgent surgical or dermatology consultation for nodule biopsy given atypical presentation 1
• Reassess wound measurements weekly and document percentage change to detect healing failure early 3, 2
• If wound fails to shrink by ≥50% after 4 weeks, reassess perfusion and infection status and escalate care 3

Common Documentation Pitfalls to Avoid

• Never record "wound improving" without objective measurements—subjective impressions delay recognition of treatment failure 3
• Do not document "no infection" based solely on absence of purulent drainage—infection requires assessment of all inflammatory signs 1
• Avoid assuming adequate perfusion from palpable pulses alone in diabetic patients—objective vascular testing is mandatory 3
• Do not dismiss the atypical nodule as benign granulation tissue without histologic confirmation 1