Wound Observation and Pressure Ulcer Staging
Key Takeaways
- Under Indiana Standard 14, the CNA observes and reports wounds but does NOT apply, change, or remove dressings — those are licensed-nurse tasks; the cream/ointment exception applies only to intact skin.
- Pressure ulcers are staged by depth of tissue damage: Stage I (non-blanchable redness), Stage II (partial-thickness skin loss), Stage III (full-thickness to visible adipose), Stage IV (full-thickness through muscle to bone/tendon), and unstageable (covered by slough/eschar).
- The Braden Scale predicts pressure ulcer risk across six subscales (sensory perception, moisture, activity, mobility, nutrition, friction/shear); lower scores mean higher risk, and a score of 18 or below generally triggers a prevention plan.
- The CNA's role is turning/repositioning per the care plan (at least every 2 hours, more often for high-risk residents), keeping skin clean and dry, protecting bony prominences, observing skin during care, and reporting any new or changed redness, breakdown, odor, drainage, or dressing that has come loose.
- A Stage I pressure ulcer is the easiest to reverse — non-blanchable redness over a bony prominence must be reported and relieved immediately; do not massage the area, because massage damages already compromised tissue.
The Standard 14 boundary: observe and report, do not dress
Indiana's 410 IAC 16.2 Standard 14 prohibits the CNA from performing wound care. The CNA does not apply, change, adjust, or remove dressings on any wound — including pressure ulcers, surgical wounds, diabetic ulcers, vascular ulcers, and abrasions. The narrow exception in Standard 14 permits the CNA to apply a non-medicated cream or ointment to intact skin as directed by the licensed nurse; once the skin is broken, that exception no longer applies and the CNA steps back. The CNA's role is to:
- Observe the skin and any visible wound during routine care (bathing, turning, dressing changes by the nurse, ambulation).
- Protect intact skin by keeping it clean, dry, moisturized with non-medicated lotion on intact skin only, and protected from friction and shear.
- Reposition the resident per the care plan to relieve pressure over bony prominences.
- Report any new or changed skin finding to the licensed nurse — promptly, before the area worsens.
A common trap on the exam: "The CNA notes a dressing has come loose. What should the CNA do?" The answer is report to the nurse — the CNA does not retape, replace, or remove the dressing.
Pressure ulcer staging (NPIAP/EPUAP stages)
Pressure ulcers are classified by the deepest layer of tissue involved. Staging describes the depth of damage, not the size or cause. The table below is the staging scheme every CNA must recognize.
| Stage | Appearance | What it means | What the CNA does |
|---|---|---|---|
| Stage I | Non-blanchable redness over a bony prominence — skin is intact but erythema does not fade when pressed | Earliest pressure damage; reversible if pressure is relieved immediately | Report immediately. Reposition off the area. Do NOT massage. Recheck on next turn. |
| Stage II | Partial-thickness skin loss — open shallow ulcer, pink wound bed, may present as an intact or ruptured serum-filled blister | Epidermis and part of dermis lost; heals with good care | Report. Keep off the area. Keep clean and dry. Do not apply anything to the wound. |
| Stage III | Full-thickness skin loss — visible adipose (fat) in the wound; may have undermining and tunneling | All skin layers lost; heals slowly; high infection risk | Report. Offload completely. Observe for drainage, odor, fever. Do not dress the wound. |
| Stage IV | Full-thickness tissue loss — visible muscle, tendon, or bone; often has slough, eschar, undermining, and tunneling | Deep tissue loss; osteomyelitis and sepsis risk; never reaches Stage IV without serious risk | Report. Strict offloading. Watch for systemic signs (fever, confusion). Do not touch the wound. |
| Unstageable | Obscured by slough (yellow/tan/gray) or eschar (black/brown) in the wound bed — depth cannot be determined | True depth is hidden; must be debrided by the nurse before staging | Report. Keep dry and protected. Do not try to remove slough or eschar. |
Two additional classifications you should recognize:
- Deep Tissue Pressure Injury (DTPI) — persistent non-blanchable deep red, maroon, or purple discoloration, often over a bony prominence. Looks like a bruise. May evolve rapidly to Stage III or IV even with treatment. Report any new purple-maroon area immediately.
- Mucosal membrane pressure injury — pressure damage to mucous membranes (e.g., from a medical device such as a nasogastric tube). The CNA cannot stage these but reports the finding.
Trap callouts:
- Do not massage a Stage I area. Massaging already-damaged tissue causes further injury.
- Heel eschar is dry and stable. A dry, intact, intact eschar on the heel without signs of infection is the body's natural cover; the nurse decides whether to debride. The CNA reports it and keeps pressure off.
- Staging is forward-looking only. A Stage IV ulcer is still a Stage IV ulcer even as it heals; it is not "down-staged" to a Stage III as it fills in. Document the original stage in the chart and the current appearance.
The Braden Scale
The Braden Scale is the most widely used pressure ulcer risk screen in long-term care. It scores six subscales; lower scores mean higher risk.
| Subscale | What it measures | Higher score = better |
|---|---|---|
| Sensory perception | Ability to respond to pressure-related discomfort | 1 (completely limited) to 4 (no impairment) |
| Moisture | Degree of skin exposure to moisture (incontinence, perspiration) | 1 (constantly moist) to 4 (rarely moist) |
| Activity | Degree of physical activity | 1 (bedfast) to 4 (walks frequently) |
| Mobility | Ability to change and control body position | 1 (completely immobile) to 4 (no limitation) |
| Nutrition | Usual food intake pattern | 1 (very poor) to 4 (excellent) |
| Friction and shear | Amount of friction/shear during repositioning | 1 (problem) to 3 (no apparent problem) — note: only 3 levels |
Total possible score is 6 to 23. A score of 18 or below generally triggers a pressure ulcer prevention plan, although each facility sets its own cutoff. The CNA does not score the Braden Scale (the nurse does), but the CNA knows the subscales because the prevention plan acts on each one — repositioning (mobility and activity), perineal care and incontinence management (moisture), nutrition and hydration (nutrition), proper turning technique and draw sheets (friction and shear), and pressure-relief mattresses and heel protectors (sensory perception).
Turning and repositioning schedule
For a resident at risk of pressure ulcers (Braden low, immobile, incontinent, poorly nourished, or with existing pressure damage), the CNA repositions at least every 2 hours when in bed and at least every hour when in a wheelchair, and more often for high-risk residents or per the care plan. The turning schedule has four positions in a cycle: supine → right lateral → supine → left lateral (or rotate the order, but never leave the resident on one side for many hours). Alternate pressure-relief surfaces per facility policy.
Practical turning principles:
- Use a draw sheet — never drag the resident up in bed, because dragging causes friction and shear that strip the epidermis and trigger pressure damage.
- Protect bony prominences (sacrum, coccyx, ischial tuberosities, heels, elbows, ears, occiput) with offloading devices: heel-lift boots, elbow protectors, foam wedges. Heels are a high-risk site — keep them off the mattress entirely when possible.
- Keep skin clean, dry, and moisturized on intact skin. After incontinence episodes, clean and dry promptly; apply a moisture-barrier cream to intact perineal skin only if the nurse has ordered it.
- Do not leave the resident on a wet bedpan.
What the CNA reports
Report immediately any: new or worsening redness that does not blanch; blister; open area; skin tear; purple-maroon area (DTPI); black or brown eschar; slough in a wound bed; foul odor from a wound or dressing; drainage that has increased, changed color, or soaked the dressing; dressing that has come loose, slipped off, or is saturated; resident pulling at the dressing; or any sign of wound infection (fever, increased pain, warmth, redness around the wound). The CNA does not dress the wound — but the CNA's prompt report can stop a Stage I from becoming a Stage IV.
The CNA notes that a resident's wound dressing has come loose and is dangling off the wound. What is the CNA's correct action under Indiana Standard 14?
During a bed bath, the CNA finds a reddened area over the resident's sacrum that does not turn white (blanch) when pressed. How should the CNA classify and respond to this finding?
A wound is covered by a thick layer of black, hard tissue that hides the bottom of the wound. How should this wound be classified?
Which Braden Scale subscale is scored from only 1 to 3, rather than 1 to 4?