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Include undermining and tunneling measurements within the wound's depth. Undermining and tunneling are measured horizontally under the wound edges (undermining) or in a specific direction away from the wound bed (tunneling). They are separate from the maximum vertical depth of the visible wound bed itself. Combining them would lead to an inaccurate measurement of the wound's true depth and extent.

Use a ruler to measure only the wound's length and width. While length and width are essential, failing to measure and record the depth, undermining, and tunneling in a complex wound like a pressure injury would result in an incomplete and insufficient assessment of tissue damage.

Estimate the measurements visually. Accurate wound management requires precise, objective measurements to monitor healing progress. Visual estimation is subjective and prone to significant error, which can compromise treatment decisions.

Higher risk of infection. Wounds healing by primary intention generally have a lower risk of infection because the edges are closed, preventing microbial entry and reducing the exposed surface area compared to open wounds.

Increased granulation tissue formation. Secondary intention healing, which occurs in open, contaminated, or tissue-loss wounds (like large pressure injuries or burns), requires the formation of a large amount of granulation tissue to fill the wound bed before epithelialization can occur. Primary intention healing requires very little granulation tissue.

Enhanced epidermal migration. While epidermal migration (epithelialization) occurs in both, the overall process is much faster in primary intention because the epithelial cells only need to migrate across a very narrow gap. In secondary intention, the epithelium must migrate across a large surface area once the granulation tissue has filled the defect.

Use of sterile dressings. Using sterile dressings is a standard, essential practice in wound care to protect the wound from infection and maintain a moist, optimal healing environment. This promotes, rather than delays, healing.

Regular wound irrigation with saline. Regular irrigation with saline is the gold standard for cleansing open wounds. It removes debris, foreign material, and loose exudate without harming healthy cells, which is a key component of preparing the wound bed for healing.

Excessive moisture in the wound bed. While a moist wound bed is optimal for healing, excessive moisture (maceration) is detrimental because it causes the periwound skin to break down, which can enlarge the wound. However, the presence of necrotic tissue is a more direct and potent factor in stalling the core healing phases.

A smooth, pale pink appearance across the wound bed: A smooth, pale pink appearance is typical of epithelialization (the final stage of wound resurfacing), or it may indicate unhealthy, poorly perfused (hypotrophic) granulation tissue. Healthy granulation tissue is not smooth.

Dry, dark-colored tissue along the wound edges: Dry, dark-colored tissue is descriptive of eschar, a form of necrotic tissue which delays healing.

Yellow, stringy substance attached to the wound bed: A yellow, stringy, or mucoid substance is descriptive of slough, another type of necrotic tissue that must be removed for healing to proceed.

A patient with adequate hydration and skin care regimen. Adequate hydration and a good skin care regimen are preventive measures that significantly decrease the risk of developing a pressure injury.

A mobile patient with a history of diabetes. While diabetes is a risk factor due to poor circulation and neuropathy, a mobile patient can independently relieve pressure, which is the most critical factor in prevention. Therefore, they are at a lower risk than an immobile patient.

A patient who regularly changes position every hour. Regular repositioning (typically every two hours in bed, or more frequently in a chair) is the single most effective intervention for preventing pressure injuries. This patient is actively mitigating their risk.

Serosanguineous drainage: Serosanguineous drainage is a thin, watery, pink-to-light red fluid, which is a mix of serous fluid and blood. It is a normal finding in the early stages of healing, indicating capillary damage but not necessarily infection.

Serous drainage: Serous drainage is a clear, thin, watery fluid. It is considered a normal, healthy product of the inflammatory phase of wound healing.

Sanguineous drainage: Sanguineous drainage is fresh, bright red blood. It is expected immediately after an injury or surgery, or if a wound has been traumatized, but its presence alone does not indicate a bacterial infection.

Daily use of strong antiseptics: Strong, non-selective antiseptics (like povidone-iodine or hydrogen peroxide) are cytotoxic and can damage the delicate, newly formed cells (fibroblasts and epithelial cells) in the wound bed, which ultimately delays healing in a chronic wound. Gentle cleansing with saline or a specialized wound cleanser is preferred.

Immediate surgical intervention: While some chronic wounds eventually require surgical intervention (e.g., grafting or flap rotation), this is not an immediate, standard component for all chronic wounds. Initial care focuses on correcting underlying causes, proper debridement, and moisture balance.

Frequent changes of antibiotics: Antibiotics are only used if a clinical infection is confirmed, usually based on culture results, and should be used judiciously to avoid antibiotic resistance. Frequent, random changes are poor practice and do not address the core issues of chronicity.

Presence of a blister on the skin: A blister, usually indicating separation of the epidermis and dermis, is characteristic of a Stage 2 pressure injury or a Deep Tissue Pressure Injury (DTPI).

Exposed bone or muscle: Exposed bone or muscle signifies a Stage 4 pressure injury, which is full-thickness skin and tissue loss.

Presence of a deep crater in the skin: A deep crater suggests a significant loss of tissue depth, characteristic of a Stage 3 or 4 pressure injury.

Apply a hydrocolloid dressing: This is an acceptable intervention for protection but is not the most appropriate intervention to prevent progression. The most critical step is relieving pressure.

Debride the area to remove necrotic tissue: A Stage 1 pressure injury has intact skin and, by definition, does not have necrotic tissue (eschar or slough) that requires debridement.

Apply antibiotics topically: A Stage 1 pressure injury is an injury due to pressure, not an infection. Topical antibiotics are not indicated unless there is clinical evidence of infection.

Full-thickness skin loss with visible fat.: This describes a Stage 3 pressure injury.

Partial-thickness skin loss involving the epidermis and dermis.: This describes a Stage 2 pressure injury.

Deep injury extending down to the bone.: This describes a Stage 4 pressure injury.