[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Nursing](https://durgical.com/en/nursing/) › [Patient safety](https://durgical.com/en/nursing/areas/safety/) › Caring for an existing pressure injury by stage # 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. Updated Nov 12, 2026 ## Key points - No dressing works if the pressure continues: reposition on a schedule and keep the wound off the surface. - Measure length, width and depth, and any tunnelling or undermining, at every assessment. - Keep the wound bed moist but not wet; absorb excess exudate to protect the surrounding skin. - A dry, stable eschar on a heel or an ischaemic limb is usually not removed. - Refer to a wound specialist when healing does not progress. ## 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. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/nursing/caring-for-an-existing-pressure-injury-by-stage/) ## Connections ## Related 5 - [Pressure injury staging](https://durgical.com/en/nursing/pressure-injury-staging/) - [Wound care and dressings: cleaning and choosing a dressing](https://durgical.com/en/nursing/wound-care-and-dressings-cleaning-and-choosing-a-dressing/) - [Preventing pressure injuries: risk scales, repositioning and skin care](https://durgical.com/en/nursing/preventing-pressure-injuries-risk-scales-repositioning-and-skin-care/) - [Wound assessment: bed, edges, exudate and signs of infection](https://durgical.com/en/nursing/wound-assessment-bed-edges-exudate-and-signs-of-infection/) - [Patient positions: Fowler, supine, lateral, prone and others](https://durgical.com/en/nursing/patient-positions-fowler-supine-lateral-prone-and-others/) [← All of nursing](https://durgical.com/en/nursing/) 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](https://med.libretexts.org/Bookshelves/Nursing/Nursing_Fundamentals_(OpenRN)/10%3A_Integumentary/10.04%3A_Pressure_Injuries) (Open RN (Chippewa Valley Technical College), LibreTexts, 2021); [Nursing Fundamentals, 10.6: Applying the Nursing Process](https://med.libretexts.org/Bookshelves/Nursing/Nursing_Fundamentals_(OpenRN)/10%3A_Integumentary/10.06%3A_Applying_the_Nursing_Process) (Open RN (Chippewa Valley Technical College), LibreTexts, 2021); [Nursing Skills, 20.4: Wound Therapy](https://med.libretexts.org/Bookshelves/Nursing/Nursing_Skills_(OpenRN)/20%3A_Wound_Care/20.04%3A_Wound_Therapy) (Open RN (Chippewa Valley Technical College), LibreTexts, 2021); [Nursing Skills, 20.5: Wound Dressings](https://med.libretexts.org/Bookshelves/Nursing/Nursing_Skills_(OpenRN)/20%3A_Wound_Care/20.05%3A_Wound_Dressings) (Open RN (Chippewa Valley Technical College), LibreTexts, 2021). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/nursing/caring-for-an-existing-pressure-injury-by-stage/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/nursing/caring-for-an-existing-pressure-injury-by-stage/