Caring for an existing pressure injury by stage
- Safe practice
Once a pressure injury exists, care removes the pressure, treats the wound for its stage, controls moisture and supports nutrition.
What it is
Caring for a pressure injury starts with an accurate stage and measurement. Whatever the stage, the wound will not heal while pressure, shear and moisture continue: the patient is repositioned on a schedule, the wound is kept off the surface, the skin is protected and nutrition is supported. The local treatment changes with the stage: protecting intact red skin, keeping a shallow wound moist and clean, and in deep wounds managing exudate, filling dead space and removing dead tissue as ordered. Wounds that do not improve are referred to a wound specialist.
What it requires
- Stage and measure the wound at every assessment.
- Relieve pressure, friction and shear on the area.
- Control moisture from incontinence, sweat or exudate.
- Adequate nutrition and fluids, unless contraindicated.
- Dressings chosen by depth, exudate and the condition of the wound bed, as the protocol and order say.
Components
- Stage 1 (intact skin with redness that does not blanch): remove all pressure from the area and protect the skin.
- Stage 2 (partial-thickness loss or blister): keep it clean and moist and protect it from friction with the dressing the protocol sets.
- Stage 3 (full thickness, fat visible): clean, manage exudate, fill dead space loosely and remove dead tissue as ordered.
- Stage 4 (bone, tendon or muscle exposed): as stage 3, watch for bone infection, and involve the specialist team.
- Unstageable (base hidden by slough or eschar): debridement by trained staff as ordered; dry stable heel eschar is usually left.
- Deep tissue injury (purple or maroon intact skin, or a blood blister): offload completely and watch how it evolves.
How it is applied (and why)
- Stage the injury and measure length, width, depth and tunnels by the clock method — documents change over time.
- Reposition at least every 2 hours on a schedule, never onto the wound; use heel protectors and support surfaces.
- Keep the head of the bed at 30 degrees or less when possible, and move up in bed with two people and a sheet — less shear.
- Clean the wound as the protocol says, usually with saline, avoiding cytotoxic antiseptics — protects new tissue.
- Choose the dressing for depth and exudate; fill deep wounds loosely so packing comes out easily — protects granulation.
- Protect the surrounding skin with a barrier product and manage incontinence — moisture breaks down skin.
- Support nutrition and fluids and involve the nutrition team — healing needs protein and energy.
- Assess colour of the wound bed, exudate and the surrounding skin at each change — shows progress or infection.
- Refer to a wound specialist if healing stalls, and record every assessment — chronic wounds need expert care.
In nursing practice
- Call for signs of infection: more redness, warmth, swelling or pain, pus, a new bad odour or fever.
- Call if the wound does not get smaller or the dead tissue does not decrease despite care.
- Call if bone, tendon or new black tissue appears.
- Call if the patient has a sudden change in consciousness.
Common mistakes
- Changing dressings while the patient keeps lying on the wound.
- Using an alginate on a dry wound: it can injure the wound bed.
- Packing too tightly, which damages granulation tissue on removal.
- Removing a dry, stable eschar from a heel.
- Mistaking the green tint of an alginate for pus.
- Raising the head of the bed high for long periods, which increases shear on the sacrum.
Test yourself
Think of the answer, then tap the question to see it.
Why does a pressure injury not heal with dressings alone?
Because pressure, shear and moisture keep damaging the tissue. They must be removed for any dressing to work.
What is the care priority for a stage 1 pressure injury?
Removing all pressure from the area and protecting the intact skin, while finding the cause.
What is usually done with a dry, stable eschar on the heel?
It is usually left in place, because it acts as a natural cover, until the blood supply has been assessed.
How should a deep wound be packed?
Loosely, filling the dead space with the ordered material so it comes out easily without damaging granulation tissue.
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Nursing Fundamentals, 10.4: Pressure Injuries (Open RN (Chippewa Valley Technical College), LibreTexts, 2021); Nursing Fundamentals, 10.6: Applying the Nursing Process (Open RN (Chippewa Valley Technical College), LibreTexts, 2021); Nursing Skills, 20.4: Wound Therapy (Open RN (Chippewa Valley Technical College), LibreTexts, 2021); Nursing Skills, 20.5: Wound Dressings (Open RN (Chippewa Valley Technical College), LibreTexts, 2021).
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Representative model, for educational purposes only.