Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Pressure-injury prevention and management
Medicine of older adults · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Pressure injury with sepsis or deep extension
Rapid spreading erythema, crepitus, severe pain, systemic toxicity, exposed bone, suspected osteomyelitis, necrotising infection or major tissue ischaemia requires urgent treatment beyond routine dressing care.
Action: Use ABCDE and sepsis assessment, remove pressure, obtain urgent surgical and tissue-viability review, investigate deep infection and perfusion, and start antimicrobial or operative source-control treatment when clinically indicated without waiting for superficial swab results.
Overview
Identify pressure and shear risk early, classify skin and deep-tissue injury accurately, relieve causative loading immediately, and coordinate wound, nutrition, mobility, infection and community care that supports healing and prevents recurrence.
Risk assessment begins on arrival, not after redness appears. Consider mobility and ability to reposition, existing skin change, previous ulcer, perfusion, sensation, frailty, cognition, acute illness, surgery, nutrition, moisture and devices. Use a validated tool consistently while recognising that clinical changes override a previously low score. Ask the person where pain or numbness occurs and what positions are tolerable.
Inspect skin over sacrum, heels, hips, ankles, elbows, occiput and beneath every device. In darker skin, early damage may appear as colour, temperature, firmness, oedema or pain change rather than obvious redness. Blanching assessment, comparison with surrounding tissue and palpation improve recognition. Document present-on-admission findings precisely and distinguish skin intactness.
Classify pressure injury using the adopted category system. Category 1 is intact skin with non-blanching erythema. Category 2 is partial-thickness skin loss with exposed dermis. Category 3 is full-thickness skin loss, and category 4 has exposed or directly palpable fascia, muscle, tendon, cartilage or bone. Slough or eschar obscuring depth is unstageable; persistent non-blanching deep red, maroon or purple change can represent deep-tissue pressure injury.
Practice
Two practice questions
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Medicine of older adultsOriginal SBA
Preventing pressure injury
A bedbound, high-risk older adult cannot reposition independently and has intact skin. Which prevention plan best follows NICE guidance?
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Remove the cause immediately. Reposition according to individual risk, comfort, respiratory and spinal needs; fully offload heels with equipment that floats them rather than simply adding a ring cushion. Use a high-specification foam mattress for adults admitted to secondary care and higher-specification dynamic support when pressure cannot be adequately redistributed. Assess seating and wheelchair cushions with OT or specialist services.
NICE provides minimum repositioning frequencies for adults unable to reposition: at least every six hours when at risk and at least every four hours when at high risk. These are not maximum targets; active damage, pain, instability, tissue response and surface may require a different schedule. Record position, tolerance and skin response. Avoid dragging by using appropriate handling equipment and enough trained staff.
Manage microclimate and moisture. Clean urine or stool promptly with a gentle pH-appropriate approach, pat dry and use a barrier product where moisture lesion risk exists. Treat diarrhoea, faecal loading and urinary dysfunction. Do not rub or massage pressure-prone skin, and avoid donut devices that concentrate pressure. Bedding and clothing should remain dry, smooth and free of hard objects.
Assess an established wound systematically: anatomical site, category, length, width, depth, undermining or tunnelling, wound bed, exudate, odour after cleansing, edges, surrounding skin, pain, perfusion and systemic condition. Repeat measurements consistently. Photography can support trajectory with consent and governance. Do not reverse-stage a healing wound; record it as a healing injury of its deepest known category.
Choose local treatment for healing environment and goals. Cleanse with an appropriate solution, protect surrounding skin and select a dressing that manages exudate, avoids trauma and supports comfort. Debride devitalised tissue when benefit outweighs risk using autolytic or sharp methods based on speed, perfusion, pain and expertise. Vascular assessment precedes debridement of ischaemic distal tissue.
Clinical infection is assessed through spreading erythema, warmth, swelling, increasing pain, purulent exudate, systemic signs, failure to heal and deep involvement. Superficial swabs can reflect colonisation. NICE advises systemic antibiotics for clinical sepsis, spreading cellulitis or underlying osteomyelitis, not simply a positive culture or to promote healing. Suspected bone infection requires specialist imaging and microbiology or surgical planning.
Assess nutrition and hydration with a validated screen and dietetic input for malnutrition. Provide adequate energy and protein within renal, hepatic, swallowing and preference constraints, but do not use supplements as a substitute for offloading. Give analgesia before dressing and repositioning, reviewing sedation and constipation. Maintain rehabilitation, chair time and social participation using surfaces and schedules that avoid new loading.
Plan transition by testing the actual home or care environment. Confirm mattress and cushion delivery, bed and transfer compatibility, power supply, who repositions day and night, wound-product supply, analgesia timing, nutrition, continence, district-nursing frequency and escalation. Include the person and carers and revisit goals when healing is unlikely or burden becomes disproportionate.
Key points
Assess pressure-ulcer risk at first contact and repeat after surgery, acute illness, immobility, nutritional decline or a change in care setting.
Use clinical judgement supported by a validated risk tool; a score does not replace head-to-toe skin, device, mobility and perfusion assessment.
Category 1 is intact non-blanching erythema; deeper categories reflect partial or full-thickness loss, exposed structures, unstageable eschar or deep-tissue change.
First-line prevention is immediate pressure redistribution: individual repositioning, heel offloading, a high-specification foam mattress and equipment matched to chair, bed and transfer needs.
NICE advises helping at-risk adults who cannot move themselves to change position at least every six hours, and high-risk adults at least every four hours, with individualisation.
Do not massage or rub vulnerable skin; manage moisture gently and use barrier preparation when incontinence or moisture lesions create risk.
Assess every established wound for site, category, dimensions, undermining, exudate, pain, surrounding skin, perfusion, infection, devices and photographs with consent and policy.
Debridement choice follows necrotic burden, perfusion, pain, goals and specialist skill; do not use routine antiseptics or antibiotics solely to heal an uninfected ulcer.
Aetiology
01
Sustained pressure
Body weight or a medical device compresses tissue between a surface and bone, especially at sacrum, heels and trochanters.
02
Shear and friction
Sliding in bed distorts deeper vessels, while repeated rubbing damages the surface and makes pressure effects more severe.
03
Reduced tissue tolerance
Frailty, malnutrition, oedema, anaemia, vascular disease, moisture and corticosteroids reduce resilience and healing capacity after tissue deformation.
04
Inability to reposition
Paralysis, pain, sedation, delirium, critical illness, unsuitable equipment and inadequate assistance prolong dangerous loading over vulnerable bony sites.
Pathophysiology
1
Microvascular occlusion
External pressure above local perfusion pressure reduces oxygen delivery and waste removal, causing ischaemic cell injury.
2
Deep shear deformation
Internal tissue layers move differently over bone, damaging muscle and vessels before the skin necessarily breaks.
3
Reperfusion and inflammation
Repeated loading and release can amplify oxidative and inflammatory injury around already vulnerable tissue during recurring pressure cycles.
4
Moisture-associated barrier loss
Urine, stool and perspiration macerate epidermis and increase friction, producing diffuse dermatitis that can coexist with pressure injury.
5
Chronic wound failure
Necrosis, biofilm, infection, poor perfusion and repeated loading prevent granulation and epithelial closure despite technically appropriate dressings.
Clinical features and red flags
Category 1 injury
Intact localised non-blanching erythema or a comparable colour and tissue change indicates early pressure damage.
Category 2 injury
Partial-thickness loss with exposed viable dermis appears shallow and should not contain deeper granulation, slough or fat.
Category 3 or 4 injury
Full-thickness loss exposes fat or, at category 4, directly reveals deeper supporting structures.
Unstageable injury
Slough or eschar obscures the wound base, so the true depth cannot yet be determined.
Deep-tissue pressure injury
Persistent deep red, maroon or purple skin or blood-filled separation suggests deeper damage beneath the surface.
Necrotising or deep infectionRed flag
Rapid spread, severe pain, crepitus, systemic toxicity or bone exposure requires urgent specialist care.
Red flags requiring action
Pain out of proportion, crepitus, bullae, dusky spread or systemic toxicity suggests necrotising infection and requires emergency surgery.
Exposed or palpable bone, deep sinus, persistent non-healing or systemic inflammation raises osteomyelitis concern.
Black toes, absent pulses, rest pain or sharply demarcated distal necrosis requires urgent vascular assessment before routine debridement.
Investigations
01Structured risk and skin assessmentFirst stepFirst line
Why
Identify preventable pressure and device risk first line.
Interpretation and limitations
Combine clinical judgement, validated tool, mobility, nutrition, perfusion, moisture, cognition and direct inspection; repeat after change.
02Standardised wound measurement
Why
Classify injury and track healing.
Interpretation and limitations
Record site, category, dimensions, depth, undermining, bed, exudate, edges, pain and surrounding skin under a consistent method.
03Perfusion assessment
Why
Determine whether tissue can heal and debridement is safe.
Interpretation and limitations
Assess pulses, temperature and vascular symptoms and obtain specialist ankle, toe or imaging tests when ischaemia is plausible.
04Infection assessment
Why
Distinguish colonisation from invasive disease.
Interpretation and limitations
Use clinical spread, pain, systemic signs and deep findings; culture tissue or deep samples when results will guide treatment.
05Osteomyelitis investigation
Why
Evaluate persistent deep or bone-exposing wounds.
Differential diagnosis
01
Moisture-associated skin damage
Diffuse irregular superficial inflammation in an exposure field differs from a localised bony or device pressure pattern, though both can coexist.
02
Arterial ulcer
Distal punched-out pain, cool skin and poor pulses suggest ischaemia and require perfusion assessment before compression or debridement.
03
Venous or neuropathic ulcer
Gaiter oedema and venous change or plantar pressure with sensory loss points to different offloading and vascular pathways.
04
Skin tear or trauma
A flap or linear wound after handling has a distinct mechanism but still requires pressure-risk and safeguarding review.
05
Deep infection or malignancy
Persistent sinus, bone exposure, atypical growth or non-healing despite adequate care may require imaging, biopsy or specialist review.
Management
01First-line prevention routeRedistribute pressure before damage developsFirst stepFirst lineImmobility, frailty or acute illness creates pressure risk.+
1Assess skin, movement, moisture, nutrition, perfusion, devices and ability to reposition using judgement and a validated tool.
2Provide the appropriate mattress and seating, offload heels and write an individual position and handling schedule.
3Review skin response, pain, nutrition, continence and equipment after every major clinical or setting change.
02Established wound routeOffload, classify and create healing conditionsNon-blanching damage or skin loss is identified.+
1Remove pressure immediately and document category, dimensions, tissue, exudate, pain, perfusion and surrounding skin.
2Choose cleansing, dressing and debridement with tissue-viability input and treat moisture, pain, nutrition and immobility.
Complications
01
Cellulitis, osteomyelitis and sepsis
Barrier failure allows infection into soft tissue and bone, with systemic deterioration sometimes presenting as delirium.
02
Pain and sleep disruption
Wound, dressing and repositioning pain impairs sleep, mobility, nutrition and willingness to accept preventive care or rehabilitation.
03
Functional decline
Prolonged bed or chair restriction deepens sarcopenia, thrombosis, constipation and respiratory complications unless rehabilitation continues with pressure redistribution.
04
Delayed discharge and care burden
Special surfaces, dressings, repositioning and trained support can prolong admission or exceed community capacity without coordinated supply and staffing.
05
Recurrent injury
A healed site remains vulnerable if seating, nutrition, transfer technique and repositioning routines are not corrected.
Monitoring and follow-up
Inspect vulnerable skin and every device contact point at the frequency matched to current risk.
Record position changes, surface, heel offloading, tolerance and any reason the schedule could not be delivered.
Measure established wounds consistently and track tissue, exudate, pain, edges and surrounding inflammation.
Monitor temperature, physiology and inflammatory or deep-infection evidence when the wound deteriorates.
Review weight, intake, hydration, swallowing and functional rehabilitation throughout healing.
Reassess analgesia before care and monitor sedation, constipation and mobility consequences.
Confirm equipment function, product supply and trained day-night support after each transition.
Special situations
Skin colour is only one clue
Temperature, firmness, oedema and pain may reveal early damage when redness is difficult to appreciate.
Deep injury may start unseen
Muscle near bone can fail before the surface, so apparently modest skin change can deteriorate rapidly.
A schedule is a minimum framework
Tissue response and clinical state determine whether repositioning must occur more often than a nominal interval.
Dressings cannot offload
An advanced product will fail when the causal pressure, shear or device fit remains unchanged.
Healing does not reduce category
Describe progress while retaining the deepest known category rather than reverse-staging the injury.
Common pitfalls
01
Waiting for a risk score before providing an obviously needed pressure-relieving surface.
02
Using redness alone to assess early injury in all skin tones.
03
Massaging non-blanching or vulnerable skin.
04
Using a ring cushion that concentrates pressure around the wound.
05
Changing dressings repeatedly without correcting pressure and shear.
06
Treating a positive superficial swab without clinical infection.
07
Debriding ischaemic distal tissue before perfusion assessment.
08
Discharging before mattress, cushion, supply and overnight repositioning are confirmed.
Nutrition screening, adequate intake, analgesia, continence care and progressive mobility accompany wound treatment rather than being secondary extras.
The community plan must specify surface, positions, frequency, equipment, wound product, analgesia, nutrition, carers, supply and urgent escalation.
New pressure damage can be a marker of acute immobility, delirium, sepsis, poor nutrition or unsafe care and requires cause investigation.
Device-shaped injury beneath oxygen tubing, cast, splint, catheter or mask requires immediate device and fit review.
Injury inconsistent with documented care, repeated missed repositioning or unexplained bruising raises safeguarding and governance concern.
Interpretation and limitations
Use inflammatory markers and imaging with specialist microbiology and surgical assessment; superficial swabs do not confirm bone infection.
06Nutrition and swallowing assessment
Why
Find modifiable constraints on wound healing.
Interpretation and limitations
Screen weight and intake and assess swallowing, dentition, food access and renal or hepatic modifiers before setting support.
07Equipment and care-environment review
Why
Test whether offloading is delivered continuously.
Interpretation and limitations
Assess mattress, cushion, heel device, transfers, day-night staffing, power, home space and repositioning documentation.
3EscalationMeasure consistently and escalate deterioration, stalled healing, ischaemia or deep involvement rather than repeatedly changing products blindly.
03Infection escalationTreat invasive disease, not colonisationEscalationSpreading cellulitis, sepsis, increasing pain or possible bone involvement is present.+
1Assess physiology and depth, obtain appropriate cultures and imaging and seek surgical, microbiology and tissue-viability input.
2Use systemic antibiotics for sepsis, spreading cellulitis or osteomyelitis under current antimicrobial guidance and provide source control.
3Continue pressure relief, perfusion, glucose, nutrition and wound management and reassess response promptly.
04Community continuity routeMake prevention work every hourCare transfers to home, rehabilitation or a care setting.+
1Confirm equipment is present and compatible before transfer and specify positions, frequency, wound product and analgesia.
2Train the person and carers in skin checks, handling, moisture care, nutrition and urgent warning signs.
3Assign district-nursing, tissue-viability, therapy and prescribing ownership and verify supply and overnight feasibility.