Synopsis
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.
- 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.
- 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.
Key red flags
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.
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.
Rapid spread, severe pain, crepitus, systemic toxicity or bone exposure requires urgent specialist care.
Investigation priorities
Identify preventable pressure and device risk first line.
Management branches
Immobility, frailty or acute illness creates pressure risk.
- Assess skin, movement, moisture, nutrition, perfusion, devices and ability to reposition using judgement and a validated tool.
- Provide the appropriate mattress and seating, offload heels and write an individual position and handling schedule.
- Review skin response, pain, nutrition, continence and equipment after every major clinical or setting change.