Documenting Stage One Pressure Injuries: Location, Size, and Surrounding Skin Matter for Clear Nursing Notes

Documentation isn’t just a form to fill out; it’s a clear, clinical map that guides a patient’s care. When a nurse documents a stage I pressure injury, the notes should tell a complete, actionable story: where it sits, how big it is, and what the skin around it looks and feels like. If you want to communicate with other nurses, therapists, or physicians, a thorough, precise note makes a real difference in how the team responds.

Let me explain why these details matter. Stage I isn’t a mystery lesion; it’s skin that’s showing signs of pressure without breaking the surface yet. That means the body is signaling risk and a change in tissue health is possible if pressure isn’t relieved. By capturing location, size, and the condition of the surrounding skin, you give everyone who looks at the chart a reliable snapshot. They can judge whether repositioning, support surfaces, or moisture management should be adjusted. And, yes, it’s also a clear way to monitor for progression or improvement over time.

What to include in a stage I pressure injury note

There are three core elements that should appear in the chart—and honestly, when you combine them, you get a story that’s easy to follow.

• Location

• Pin down the exact spot. Is it the sacrum, heels, elbows, or another bony prominence? If the patient has multiple sites, list them separately with precise coordinates or descriptive areas.

• Why it matters: Location helps you track changes over days, plan targeted pressure relief, and coordinate care with nutrition, rehab, and skin-care teams.

• Size (in centimeters)

• Even though the skin isn’t broken, measuring size is useful. Record length and width (for example, 2 cm x 2 cm). If the site is irregular, you can approximate to the nearest half-centimeter.

• Why it matters: Size changes can signal progression or improvement. A small shift in dimensions may cue a change in pressure-relief strategy or skin assessment frequency.

• Integrity of the skin around the wound (periwound)

• Describe the surrounding skin: color changes, temperature, warmth, edema, moisture, or breakdown adjacent to the lesion.

• Note any warmth or swelling around the area and whether the color extends beyond the immediate margin.

• In stage I, you’ll often see non-blanchable redness of intact skin, but the periwound area can show subtle signs of stress—keep an eye on it.

• Why it matters: The periwound area can hint at evolving problems or risk for deterioration. If surrounding skin is warm, discolored, or swollen, it may indicate inflammation or increasing tissue stress that needs attention.

How to phrase the documentation (a practical example)

A straightforward, consistent way to write your note helps other care team members act quickly and confidently. Here’s a compact template you can adapt:

• Location: sacral area

• Size: 2 cm x 2 cm

• Skin integrity: intact with non-blanchable erythema

• Periwound: skin around the lesion warm to touch; slight edema; no drainage or open skin

• Additional observations: patient reports mild tenderness when seated; no pain at rest

That phrasing hits the essentials without overcomplicating things. You’re saying where it is, how big it is, and what the surrounding skin is doing, plus a quick note on the patient’s experience. If the site is on a face, arm, or leg, adjust the location description accordingly. And if the redness doesn’t blanch when you press it, that detail is worth including in the notes.

A quick, practical note about measuring and describing

• Use objective terms whenever possible. “2 cm x 2 cm” beats “about two centimeters.”

• Include both location and dimension in the same entry when you can, so someone reading later doesn’t have to hunt for details.

• Document any changes from the prior assessment. If the size is the same but the periwound skin looks more erythematous, say so.

• Don’t assume. If you’re unsure whether redness is blanchable, note what you observe and, if needed, reassess and document again.

Why this approach supports good care

Comprehensive notes do more than satisfy a charting requirement; they influence real-life decisions.

• Continuity across shifts: When a nurse hands off care, clear details about where the injury sits, its size, and the condition of nearby skin help the next caregiver resume with confidence.

• Timely interventions: If the periwound skin becomes warmer or more swollen, the team can adjust pressure redistribution strategies, support surfaces, or repositioning schedules sooner rather than later.

• Quality of life: Thorough documentation supports decisions that protect the patient’s comfort and dignity. Simple notes about redness and warmth can lead to changes that reduce discomfort and improve overall well-being.

Common pitfalls to avoid

• Skipping the location: It’s not enough to say “bed area”—be precise. The exact site matters for tracking and treatment planning.

• Skipping measurements: Even small stage I changes matter. A precise size helps you notice trends later.

• Failing to describe surrounding skin: The periwound skin can reveal early trouble. Don’t overlook it.

• Being vague about color or temperature: Use clear terms like “non-blanchable erythema” or “warm to touch” rather than vague descriptors such as “reddish” or “not right.”

Putting it all together in the bigger picture

Think of the assessment as a short story that others can read at a glance and immediately know what to do. The three pillars—location, size, and the integrity of the surrounding skin—are the plot lines. The patient’s experience (discomfort, seating tolerance, and observed sensations) adds character to the narrative. And the care plan, guided by these notes, becomes the resolution: pressure offloading, protective barriers, skin care, and consistent monitoring.

A final note on tone and clarity

You want your notes to be accurate and easy to comprehend. That means using standard terms that other clinicians expect, avoiding ambiguity, and keeping your entries readable. It’s not about writing a novel; it’s about clear, actionable communication that helps prevent progression and supports healing.

If you’re exploring ATI’s physical assessment topics, you’ll notice that good documentation sits at the intersection of observation and action. It’s where clinical judgment begins to take shape in a way that others can follow. The compact, precise notes you craft about a stage I pressure injury—location, size, periwound skin—become a roadmap for ongoing, thoughtful care.

A quick recap, for quick recall

• Always include location, size in centimeters, and the condition of the skin around the injury.

• Note if the redness is non-blanchable and whether the surrounding skin is warm, swollen, or discolored.

• Document changes over time to help the team decide on interventions.

• Use clear, objective language so any clinician reading the chart understands exactly what’s happening.

If you want to keep this level of clarity as you move through patient care, remember: the notes you write are a form of communication that travels with the patient. They ride along in the chart, to the next shift, to the wound team, and to the physician’s desk. The moment you capture precise location, measurable size, and a careful read of the surrounding skin, you’ve set the stage for timely, effective care—and that’s what great nursing documentation is all about.