Synopsis
Detect pressure injury early across skin tones, assign a defensible category without understaging concealed depth, remove pressure and shear, and deliver individualised prevention, wound, nutrition and infection care.
- Pressure injury is local skin and soft-tissue damage caused by sustained pressure or pressure with shear, usually over bone or beneath a medical device.
- Category 1 is intact skin with persistent non-blanching change; in dark skin, new temperature, firmness, bogginess, pain or a purple-grey hue may precede an obvious colour contrast.
- Category 2 is partial-thickness skin loss with exposed dermis or an intact or ruptured serum blister; slough, fat and granulation are not category-2 features.
- Category 3 exposes full-thickness skin and visible adipose or granulation without exposed fascia, muscle, tendon or bone; undermining and tunnelling may be present.
- Category 4 has exposed or directly palpable deep structures such as fascia, muscle, tendon, cartilage or bone and carries high osteomyelitis risk.
- If slough or eschar obscures the base, record unstageable until depth is revealed; persistent deep red, maroon or purple discoloration or a blood-filled blister indicates deep-tissue pressure injury.
- First-line prevention combines prompt risk and skin assessment, individual repositioning, heel offloading, pressure-redistributing support, moisture control, nutrition and device checks.
- NICE adult minimums are repositioning at least every six hours when at risk and every four hours when high risk, but discomfort, tissue response and instability can require a shorter tailored interval.
- Do not massage or rub threatened skin, use water-filled gloves or improvised rings, or substitute a risk score for direct inspection.
- Systemic antibiotics do not heal an uninfected pressure ulcer; use them for sepsis, spreading cellulitis or osteomyelitis and combine with source, perfusion and wound management.
Key red flags
Fever, hypotension, spreading erythema, crepitus, foul wet necrosis with decline, pain out of proportion, exposed bone, new neurological deficit, absent pulses, rapidly worsening device indentation or failure to improve after pressure removal requires urgent escalation.
Full-thickness skin and tissue loss exposes or permits direct palpation of fascia, muscle, tendon, cartilage or bone and may tunnel extensively.
Intact or broken skin shows persistent deep red, maroon, purple or dark discoloration or a blood-filled blister after intense pressure or shear.
Investigation priorities
Identify pressure exposure and modifiable tissue vulnerability at admission and after clinical change.
Management branches
A person enters hospital or care with reduced mobility, sensation, perfusion, nutrition or a pressure-causing device.
- Complete risk and skin assessment promptly and after every material change, involving the person and carers in pain, movement and skin-history information.
- Place high-risk adults on an appropriate high-specification foam or higher-level pressure-redistributing surface, float heels and pad or reposition devices without compromising function.
- Write a repositioning and inspection schedule with technique, assistance and named responsibility and review tissue response rather than relying on a turn chart alone.
A pressure injury is confirmed and no emergency infection or ischaemia requires immediate transfer.
- Offload the site completely where feasible, upgrade the mattress or seat surface, control shear during transfers and protect skin from urine, stool, sweat and adhesive trauma.
- Clean with an appropriate solution, select a moisture-balancing dressing based on exudate, pain and surrounding skin and give analgesia before handling.
- Set nutrition, mobility and continence plans and review category and dimensions regularly, escalating if deeper tissue declares itself despite correct unloading.