A pressure injury is staged only when you can see the base, prevented by offloading rather than by dressings, and never reverse-staged. A leg ulcer is a finding, not a diagnosis — and the treatment for one type actively harms another. Stage nine wounds, build a Braden-driven plan and decide who may carry each part of it out, then let the ankle–brachial index decide whether compression goes on.
Nine wounds on one unitStage each one against current criteria. Two of them cannot be staged, one of them is not a pressure injury at all, and one of them is a trap that tempts you to reverse-stage.
The wound in front of you
Mrs. Levy, day 3 after a hemiarthroplastyScore the six Braden subscales. Then read the plan the score builds — and notice that the plan follows the lowest subscale, not the total. A patient who scores low only on moisture needs a barrier and a continence plan, not a specialty mattress.
Now assign the plan — RN or unlicensed assistive personnel?
Step 1 · Which ulcer is this?
Step 2 · Does compression go on?
Try any ankle–brachial index
ABI
1.05
Skin clinic · five lesionsEvery one of these is on a patient you already have. Decide whether it gets reassurance, watchful photography, or a biopsy today — and remember that a dressing is never the answer to a lesion that will not heal.
Lesion
The staging rules that decide these
Category
Defining finding
Practice implication
Two rules that override everything: you cannot stage a wound whose base you cannot see, and you never reverse-stage — a healing stage 4 is a “healing stage 4,” because muscle and fat are replaced by scar, not by the original tissue.
18
Mild riskBraden 6–23; lower is worse
The ankle–brachial index is the gatekeeper
What you are looking for
Lesion
Looks like
Behaves like
Basal cell carcinoma
Pearly, translucent papule with telangiectasias and a rolled border; may ulcerate, scab and re-bleed
The most common human cancer; invades locally, rarely metastasises
Squamous cell carcinoma
Firm, scaly, hyperkeratotic or ulcerated nodule on sun-exposed skin, arising from actinic keratoses
Can metastasise; far higher risk in transplant recipients, chronic wounds and old burn scars
Melanoma
Asymmetry, Border irregularity, Colour variegation, Diameter over 6 mm, Evolving — plus the “ugly duckling” that matches none of the patient’s other moles
The one that kills; full-thickness biopsy, and Breslow depth in millimetres drives prognosis and sentinel node biopsy
Marjolin ulcer
A non-healing ulcer inside a mature burn scar or chronic wound
Squamous cell carcinoma until biopsy says otherwise
Prevention teaching, said concretely: broad-spectrum SPF 30 or higher applied 15–30 minutes before exposure and reapplied every two hours and after swimming; protective clothing and a wide-brimmed hat; shade between 10:00 and 16:00; no tanning beds at any age; monthly self-examination including the scalp, the soles and between the toes.