Eduovisual
Skin & Subcutaneous Tissue
Pressure injuries: staging, prevention, and management
— Prevalence 5–15% in acute care; up to 25% in long-term care and 30% in spinal cord injury units.
— Stage 3, 4, unstageable, and deep tissue pressure injuries (DTPI) acquired in-hospital are CMS "never events" — non-reimbursable hospital-acquired conditions (HACs).
— Estimated cost $20,000–$150,000 per advanced injury; contributes to >60,000 US deaths annually.
— Sustained capillary closure pressure (>32 mmHg) → ischemia, reperfusion injury, lymphatic obstruction, and cytokine-mediated necrosis.
— Shear (parallel forces, e.g., head of bed >30°) and friction amplify injury at lower pressures.
— Moisture (incontinence, sweat, wound drainage) macerates skin and lowers threshold for breakdown.
— Any patient immobile >2 hours (OR table, ED boarding, ICU, post-op).
— Sensory deficit: SCI, stroke, dementia, sedation, neuropathy.
— Malnutrition (albumin <3.5, unintentional weight loss, BMI <18.5), dehydration.
— Incontinence, devices (NG tubes, ETT, O₂ tubing behind ears, casts, cervical collars, SCDs).
— Vasopressor use, hypotension, anemia, end-of-life states (Kennedy terminal ulcer).
Board pearl: A pressure injury developing within hours in a hemodynamically unstable or dying patient with a butterfly/pear-shaped sacral lesion is a Kennedy terminal ulcer — a sign of impending death, not a quality failure. Document accordingly to avoid misclassification as a preventable HAC.
— Stage 1 can appear within 30–60 minutes of unrelieved pressure; DTPI may take 24–72 hours to declare its full depth ("evolving injury").
— Patients with intact sensation report localized pain, burning, or tenderness before visible skin change — pain often precedes erythema and is an early warning sign.
— Duration of immobility (surgery length, ED boarding hours, time since last turn documented in nursing flowsheet).
— Prior pressure injuries (strongest predictor of new injury); spinal cord level if SCI.
— Continence pattern, frequency of brief changes, use of barrier creams.
— Nutritional intake: protein servings/day, recent weight loss, dysphagia, NPO duration.
— Devices in continuous contact: BiPAP mask, nasal cannula, Foley, telemetry leads, casts.
— Caregiver capacity at home, type of mattress/cushion, repositioning schedule.
— Braden Scale (6 subscales: sensory perception, moisture, activity, mobility, nutrition, friction/shear). Score ≤18 = at risk; ≤12 = high risk. Mandated on admission and at least daily in acute care, every shift in ICU.
— Norton Scale — older, used in LTC.
— PUSH tool tracks healing, not risk.
— Prolonged OR time (>3 hours), hypotension intraop, hypothermia.
— "Bruise that won't fade" over a bony prominence = suspect DTPI until proven otherwise.
— Foul odor, fever, new delirium, or unexplained leukocytosis in a known ulcer = suspect osteomyelitis or sepsis.
Step 3 management: On admission, document a Braden score within 8 hours and a head-to-toe skin assessment within 24 hours — failure to do so is the most commonly tested patient safety lapse and a Joint Commission deficiency. Reassess after every transfer of care (OR → ICU, ICU → floor) because shear during transfers is when undetected injuries are missed.
Key distinction: Pressure injuries are staged by deepest visible tissue; once staged, they do not "downstage" as they heal — a healing Stage 4 is documented as "healing Stage 4," not Stage 2. Reverse staging is incorrect and a common documentation error penalized in audits.
— Location, stage, length × width × depth (cm) using sterile cotton-tip applicator.
— Wound bed: % granulation, % slough, % eschar, % epithelialization.
— Exudate: amount (none/scant/moderate/heavy), type (serous/sanguineous/purulent).
— Edges: attached, rolled (epibole), undermined, tunneled — probe with sterile applicator and document clock-face position and depth.
— Periwound skin: maceration, erythema, induration, warmth.
— Odor (after cleansing — pre-cleansing odor is not reliable).
— Pain score.
— CBC with differential, CRP, ESR, blood cultures × 2 if febrile or septic.
— Albumin and prealbumin (half-life 2 days, better acute marker); total protein.
— HbA1c, glucose — uncontrolled DM impairs healing (target A1c <8% for wound healing; tight control if surgical candidate).
— BMP for renal function (affects antibiotic dosing and protein needs).
— Vitamin levels only if clinically deficient: vitamin C, zinc, vitamin D (routine supplementation NOT recommended without deficiency — overuse of zinc impairs copper absorption and healing).
— Do NOT swab the wound surface for culture; it grows colonizers and misleads therapy.
— Obtain culture by tissue biopsy or curettage from the wound base after debridement and cleansing, or by Levine technique if biopsy not feasible.
— Quantitative culture >10⁵ CFU/g supports infection.
Board pearl: A "positive wound swab" in an afebrile patient with a clean-appearing ulcer is colonization, not infection — treating it with antibiotics is a classic Step 3 wrong-answer trap and contributes to antimicrobial stewardship failures and C. difficile risk.
— Stage 3 or 4 ulcer over a bony prominence with exposed bone, non-healing >4–6 weeks despite optimal care, systemic signs of infection, or planned flap reconstruction.
— Sensitivity 90%, specificity 80%+ for osteomyelitis.
— Distinguishes soft-tissue abscess, sinus tracts, marrow edema.
— Limitations: cannot always differentiate reactive marrow changes from true infection adjacent to chronic ulcer; SCI patients may have baseline marrow changes.
— Indicated before prolonged antibiotic course for chronic osteomyelitis.
— Obtain through uninvolved skin when possible to avoid contamination; hold antibiotics ≥2 weeks prior if patient is clinically stable.
— CT for surgical planning and to detect gas, abscess, or foreign body.
— Tagged WBC scan/PET useful when MRI contraindicated (hardware, pacemaker).
— Doppler/ABI for sacral or heel ulcers with concern for arterial compromise — ABI <0.5 = critical limb ischemia, refer vascular before debridement of heel.
Step 3 management: "Probe-to-bone" at bedside with a sterile blunt probe in a Stage 4 ulcer has PPV ~89% for osteomyelitis in diabetic/pressure ulcers — a positive probe-to-bone in a chronic ulcer is sufficient to obtain MRI and consult ortho/plastics, even before labs return.
— Repositioning every 2 hours in bed, every 1 hour in chair; 30° lateral tilt (NOT 90° side-lying, which loads the trochanter); avoid head of bed >30° unless medically required (reduces sacral shear).
— Pressure-redistributing surface: high-specification foam mattress for all at-risk patients; alternating-pressure or low-air-loss mattress for Braden ≤12, existing Stage 3/4, or post-flap.
— Heel offloading — float heels with pillow under calves, or heel suspension boots. Heel ulcers are second most common and the most preventable.
— Skin care: pH-balanced cleansers, barrier creams (zinc oxide, dimethicone) for incontinence, prompt brief changes, avoid massage of bony prominences (causes deep tissue damage).
— Nutrition optimization: screen with MUST or MNA; oral nutritional supplements with arginine, zinc, antioxidants for high-risk patients (level 1 evidence reduces incidence).
— Moisture management: treat incontinence-associated dermatitis (IAD) separately — barrier products, fecal management systems for liquid stool.
— Mobilization: out of bed as early as safe; PT/OT consult.
— Rotate pulse-ox sites q4h, pad under O₂ tubing behind ears, reposition ETT/NG q shift, ensure cervical collars and casts are properly fitted, check under SCDs daily.
— Account for ~30% of all hospital-acquired pressure injuries.
CCS pearl: On any CCS case with an immobile patient, order "skin assessment," "Braden score," "turn q2h," "pressure-redistribution mattress," and "nutrition consult" in the initial order set — these are scored as appropriate preventive care and missing them costs points on long-stay or ICU cases.
— Dry wound → hydrogel (donates moisture) + secondary cover.
— Minimal exudate, granulating → hydrocolloid or thin foam; protects and maintains moist environment.
— Moderate–heavy exudate → foam, alginate, or hydrofiber; change when strikethrough occurs (typically q1–3 days).
— Infected/heavy bioburden → silver-impregnated dressing or cadexomer iodine for 2 weeks, then reassess; do not use silver indefinitely.
— Tunneling/undermining → loosely pack with alginate ribbon or hydrofiber; never overpack (causes pressure necrosis).
— Stable dry eschar on heel → leave intact, paint with povidone-iodine, offload — do NOT debride.
— Topical antibiotics (mupirocin, neomycin, bacitracin) are NOT recommended for pressure ulcers — sensitization and resistance.
— Cellulitis/soft tissue infection: cover MRSA + streptococci (e.g., vancomycin or linezolid) ± gram-negative/anaerobe coverage for sacral/perineal ulcers (piperacillin-tazobactam).
— Osteomyelitis: culture-directed, 6 weeks IV typically, after surgical debridement.
Board pearl: Routine systemic antibiotics for a non-infected pressure ulcer delay healing by selecting resistant flora and do not improve outcomes — antibiotics are for clinical infection (advancing erythema, warmth, purulence, fever, leukocytosis, bacteremia), not for colonized wounds.
— Sharp/surgical (fastest): Scalpel/curette at bedside or OR; required for extensive necrosis, advancing infection, sepsis source control. CCS action: call surgery STAT for sepsis from a Stage 4 sacral ulcer.
— Enzymatic: Collagenase ointment daily — selective, useful when sharp debridement contraindicated (anticoagulation, palliative).
— Autolytic: Hydrogels/hydrocolloids — slowest, for stable wounds with minimal necrosis.
— Mechanical: Wet-to-dry dressings are outdated and discouraged — non-selective, painful, damage granulation. A common Step 3 wrong answer.
— Biologic (maggot/larval): Niche use for resistant biofilm.
— Indications: Stage 3/4 ulcers that fail 4–6 weeks of optimal conservative therapy, in patients with stable medical status and ability to offload postop.
— Procedures: myocutaneous flaps (gluteus maximus for sacral, tensor fascia lata for trochanteric, hamstring for ischial).
— Pre-op: nutrition optimization (albumin >3, prealbumin >15), smoking cessation, glycemic control, treat osteomyelitis, urinary/fecal diversion if needed.
— Post-op: air-fluidized bed × 4–6 weeks, no sitting/pressure on flap × 6 weeks, gradual sitting protocol.
— Hyperbaric O₂: not standard for pressure ulcers (unlike diabetic foot); limited evidence.
— Electrical stimulation: weak recommendation for recalcitrant Stage 2–4.
— Skin substitutes/grafts: select cases.
Step 3 management: Before any flap procedure, ensure the patient has reliable offloading at home or placement plan — recurrence rates exceed 60% within 1 year if the underlying pressure exposure isn't addressed. Document this counseling and arrange wheelchair seating evaluation pre-op.
— Age-related changes: thinner dermis, reduced subcutaneous fat, decreased capillary density, slower epidermal turnover, reduced sensation, polypharmacy-induced sedation/hypotension.
— Higher prevalence of malnutrition, dehydration, dementia (cannot reposition or report pain), incontinence.
— Avoid adhesive removal injuries — use silicone-based dressings and adhesive removers; skin tears are common but are NOT staged as pressure injuries.
— Polypharmacy review: minimize sedatives, anticholinergics, and chronic steroids that impair healing.
— Falls vs. pressure trade-off: bed/chair alarms and restraints can paradoxically increase immobility and pressure injury risk — restraint-free care is preferred.
— Protein needs are competing: wound healing needs 1.25–1.5 g/kg/day, but pre-dialysis CKD recommends restriction. In dialysis patients, protein goal is 1.2–1.4 g/kg/day — healing needs are usually met.
— Antibiotic dose adjustment (vancomycin levels, avoid nephrotoxic aminoglycosides if avoidable).
— Uremia impairs wound healing and platelet function (bleeding with debridement).
— Calciphylaxis can mimic pressure injury in dialysis patients — biopsy if necrotic ulcer in unusual location (thigh, abdomen).
— Low albumin (synthesis failure) ≠ malnutrition alone — don't over-supplement protein if hepatic encephalopathy risk.
— Coagulopathy (elevated INR) increases bleeding with sharp debridement — correct with vitamin K/FFP if active intervention planned.
— Ascites and edema strain skin and predispose to breakdown.
Key distinction: Low albumin in a chronically ill elderly patient reflects inflammation/illness severity more than nutritional status — use prealbumin trend, weight change, oral intake, and clinical context, not albumin alone, to assess nutritional adequacy and response to interventions.
— Lifetime pressure injury risk >80%; #1 cause of rehospitalization in chronic SCI.
— Ischial tuberosity ulcers from sitting are most common — wheelchair pressure mapping and pressure-redistribution cushion (ROHO, gel) mandatory.
— Teach pressure reliefs every 15–30 minutes (push-ups, lateral tilts).
— Autonomic dysreflexia can be triggered by pressure injury pain in T6 and above — sudden hypertension, headache, sweating above the lesion.
— Occiput is the #1 site (large head-to-body ratio); next are ears, sacrum, heels.
— Device-related injuries dominate: BiPAP, pulse-ox, IV boards, ECMO cannulae.
— Use Braden Q scale (modified for pediatrics, adds tissue perfusion/oxygenation).
— Neonatal skin is thin, easily injured by tape — use silicone dressings, gentle adhesives.
— Goals shift from healing to comfort, dignity, odor and exudate control, pain management.
— Kennedy terminal ulcer and SCALE (Skin Changes At Life's End) — recognize as unavoidable; document with family.
— Reposition for comfort, not on a strict 2-hour schedule if it causes distress.
— Topical lidocaine, opioids for dressing-change pain; metronidazole gel for odor control.
— Skin folds (pannus, gluteal cleft) develop intertriginous moisture-associated damage often mistaken for Stage 1/2 — keep dry, antifungal as needed.
— Special bariatric beds and lifts to prevent staff injury and shear during repositioning.
— Atypical sites: under pannus, between thighs, behind knees from sitting.
Board pearl: A non-healing, undermined ulcer in a chronic SCI patient with foul drainage and chronic inflammation may harbor Marjolin's ulcer (SCC arising in chronic wound) — biopsy any pressure ulcer present >3 months without healing or with abnormal granulation tissue.
— Local wound infection: advancing erythema (>2 cm), warmth, tenderness, purulence, friable granulation, delayed healing.
— Cellulitis of surrounding skin.
— Abscess formation in undermined tracts — requires I&D.
— Sinus tracts and fistulas — can communicate with bowel, bladder, joint space.
— Heterotopic ossification within chronic wounds (esp. SCI).
— Marjolin's ulcer: squamous cell carcinoma in chronic non-healing wound (>3 months) — biopsy any suspicious change.
— Osteomyelitis (most common in Stage 4 sacral, ischial, trochanteric ulcers) — chronic, polymicrobial, requires surgical + 6 weeks IV antibiotics.
— Septic arthritis of hip from trochanteric ulcer.
— Bacteremia with translocation — Staph aureus (including MRSA), enterococci, anaerobes, gram-negatives.
— Sepsis and septic shock — pressure ulcer–related sepsis carries mortality 50–60%.
— Endocarditis seeding from bacteremia.
— Hypoalbuminemia from chronic exudate loss (large wound = 50+ g protein/day lost).
— Anemia of chronic disease.
— Chronic pain, depression, social isolation, body image distress.
— Loss of independence, long-term placement, caregiver burnout.
— CMS does not reimburse hospital-acquired Stage 3/4/unstageable/DTPI — direct hospital loss.
— Litigation: among the most common nursing home and hospital lawsuits in the US ("failure to prevent" is a frequent plaintiff theory).
Step 3 management: New fever, leukocytosis, hypotension, or altered mental status in a patient with a Stage 3/4 ulcer → blood cultures × 2, lactate, broad-spectrum antibiotics (vancomycin + piperacillin-tazobactam), fluid resuscitation, urgent surgical evaluation for debridement — pressure ulcer sepsis requires source control, not antibiotics alone.
— Suspected sepsis from a wound (fever + hypotension/tachycardia + Stage 3/4 ulcer).
— Cellulitis with systemic signs, failed outpatient antibiotics, or in immunocompromised host.
— Suspected osteomyelitis requiring biopsy/debridement.
— Need for surgical debridement of extensive necrotic tissue.
— Uncontrolled pain requiring IV opioids.
— Inability to manage wound at home (lack of caregiver, supplies, or skilled nursing).
— Septic shock requiring vasopressors.
— Necrotizing soft tissue infection (rapid spread, crepitus, bullae, pain out of proportion, gas on imaging) — surgical emergency, broad-spectrum antibiotics including clindamycin for toxin suppression.
— Wound care/CWOCN nurse: all Stage 2 and higher; ideally within 24 hours of identification.
— Plastic surgery: Stage 3/4 not healing at 4–6 weeks despite optimal care, candidates for flap reconstruction.
— General/orthopedic surgery: urgent debridement, suspected osteomyelitis, sepsis source control.
— Infectious disease: osteomyelitis, recurrent bacteremia, complex/resistant organisms.
— Nutrition: Stage 3/4 or any non-healing wound, BMI <18.5 or recent weight loss.
— Physical/occupational therapy: mobility, pressure relief training, wheelchair seating eval.
— Palliative care: end-of-life or goals-of-care misalignment.
— Psychiatry/social work: depression, placement, caregiver concerns.
— Communicate stage, location, dressing regimen, last assessment, devices.
CCS pearl: On a CCS sepsis case where the source is a sacral ulcer, simultaneous orders should include: blood cultures × 2, lactate, IV vancomycin + piperacillin-tazobactam, IVF bolus, surgery consult for debridement, wound care consult, and continued q2h turning — sequential ordering loses points; concurrent management wins.
— Diffuse, ill-defined erythema in skin folds and over the buttocks/perineum, often with satellite lesions if candidal overlay.
— Typically symmetric, not localized to a bony prominence, and shape conforms to moisture exposure, not pressure point.
— Tx: barrier cream (zinc oxide), manage incontinence, antifungal if candidal.
— Traumatic separation of epidermis from dermis (shear/friction during transfer or tape removal).
— Common in elderly forearms and shins; NOT staged as pressure injuries — use ISTAP classification.
— Erythema, blistering, or epidermal stripping under tape/dressing edges.
— Prevention: silicone-based adhesives, gentle removal, skin prep barriers.
— Plantar surface, weight-bearing area (metatarsal heads, heel), punched-out, surrounded by callus, in patient with peripheral neuropathy.
— Pathophysiology: neuropathy + pressure + ± ischemia, NOT classified as a pressure injury despite pressure component.
— Distal toes, dorsum of foot, lateral malleolus; "punched-out," pale base, painful, cool extremity, diminished pulses, ABI <0.9.
— Heel ulcers in patients with PAD may be mixed pressure + arterial — check ABI before debridement.
— Medial gauche/malleolus, irregular borders, shallow, heavy exudate, hemosiderin staining, edema.
— Tx: compression (after ruling out arterial disease).
Key distinction: Location and shape distinguish pressure from moisture damage — pressure injuries are localized over bony prominences with shapes mirroring the underlying bone; IAD is diffuse, in skin folds, and follows the contour of moisture exposure. Both can coexist (combined IAD + Stage 2 sacral pressure injury) and require both interventions.
— Dialysis or advanced CKD patient, painful violaceous retiform necrotic plaques on adipose-rich areas (thighs, abdomen, breasts) — atypical locations for pressure.
— Dx: biopsy showing calcified small vessels; treat with sodium thiosulfate, manage calcium-phosphate product, wound care.
— Mortality 60–80% at 1 year.
— Rapidly expanding ulcer with violaceous, undermined border and pathergy (worsens with debridement).
— Associated with IBD, RA, hematologic malignancy.
— Tx: immunosuppression (steroids, cyclosporine, biologics) — debridement worsens it. A classic Step 3 trap: don't debride a pyoderma gangrenosum lesion mistaken for an infected pressure ulcer.
— Palpable purpura progressing to necrotic ulcers, often on legs, with systemic features.
— Marjolin's ulcer (SCC in chronic wound), basal cell, melanoma — biopsy any chronic non-healing wound.
— Pain out of proportion, rapid spread, bullae, crepitus, hemodynamic instability — surgical emergency.
— Grouped vesicles, dermatomal (zoster) or perineal (HSV), preceding pain — not pressure-induced.
— Sloughing skin in setting of new medication, mucosal involvement — not pressure.
— Heating pads, hot packs, urine/stool maceration with heat — pattern follows exposure, not bony prominence.
Board pearl: A rapidly worsening ulcer that enlarges with each debridement attempt and has a violaceous, undermined border in a patient with IBD or RA is pyoderma gangrenosum — stop debriding, biopsy edge to exclude infection/malignancy, start systemic immunosuppression.
— Confirmed pressure-redistribution mattress at home (Medicare covers Group 1–3 support surfaces with documentation of qualifying ulcer/condition).
— Wheelchair cushion fitted (ROHO, gel, or air) for non-ambulatory patients — Medicare covers with seating eval.
— Caregiver trained in repositioning, transfer techniques, dressing changes, and skin inspection (return demonstration documented).
— Written wound care orders: cleanser, primary dressing, secondary dressing, frequency, signs to report.
— Home health referral with wound care nursing, PT, OT.
— Adequate supplies for at least 2 weeks; DME order placed before discharge.
— Nutrition plan: oral supplements (e.g., arginine/zinc/antioxidant–enriched), follow-up with dietitian.
— Incontinence management plan and supplies.
— SCI patients: lifelong daily skin inspection (mirror or caregiver), pressure-relief schedule, annual wheelchair seating reassessment, smoking cessation (smoking doubles recurrence).
— LTC residents: facility-level QI bundles, Braden on admission and weekly, turning schedules with documentation.
— Optimize glycemic control (A1c <8% for wound healing).
— Minimize systemic steroids; if unavoidable, vitamin A 25,000 IU/day may partially offset (consult before initiating).
— Smoking cessation counseling, varenicline/bupropion/NRT as appropriate.
— Manage edema (diuretics, compression after confirming arterial adequacy).
— Tetanus update if last >5 years and contaminated wound.
— Pneumococcal and influenza vaccination in chronically ill patients.
Step 3 management: Before discharging any patient with a Stage 3/4 pressure ulcer, confirm DME (mattress, cushion), home health wound care, dietitian follow-up, and a scheduled wound clinic visit within 1–2 weeks — gaps in this transition are the most common cause of 30-day readmission and the most common patient-safety failure tested.
— Stage 1: resolves in days with offloading.
— Stage 2: 1–3 weeks.
— Stage 3: 1–4 months.
— Stage 4: 3 months to >1 year; many never fully heal.
— Expect ~20–40% wound area reduction at 2–4 weeks if healing trajectory is adequate.
— Measure length × width × depth weekly; track on PUSH tool (Pressure Ulcer Scale for Healing) — score combines area, exudate, tissue type; declining score = healing.
— Photograph at standardized intervals.
— Reassess pain, nutritional intake, mood, caregiver capacity.
— Reassess pressure-redistribution surface and offloading adherence.
— <30% area reduction at 4 weeks → reconsider diagnosis (biopsy for malignancy or atypical etiology), evaluate for osteomyelitis (MRI), assess perfusion (ABI), reassess nutrition, infection, offloading adherence.
— PT: progressive mobility, transfer training, pressure-relief techniques.
— OT: ADL adaptation, seating/positioning, home safety.
— Wheelchair seating clinic: pressure mapping every 1–2 years and after any significant weight change in SCI/chronic users.
— Screen for depression (PHQ-9) — chronic wounds correlate with depression and impaired healing.
— Caregiver respite, support groups.
— Stage, location, measurements, treatment, response — clear documentation is medicolegal protection and CMS-required.
CCS pearl: On a follow-up clinic visit for a Stage 3 sacral ulcer at 4 weeks, if the wound has not reduced by ≥30%, the highest-yield CCS actions are: order MRI to rule out osteomyelitis, reassess nutrition (prealbumin), confirm offloading adherence, and consider plastic surgery referral — escalating care, not just changing the dressing, scores correctly.
— Hospital-acquired Stage 3, 4, unstageable, and DTPI are non-reimbursable HACs; reported publicly on Hospital Compare.
— Nursing home Stage 2+ pressure ulcers are reported on Nursing Home Compare.
— Joint Commission tracer methodology audits skin assessment timing and Braden documentation.
— "Present on admission" (POA) designation is critical — must document complete skin assessment within 24 hours of admission with photograph if possible. Failure to document POA = presumed hospital-acquired.
— Use precise NPIAP staging language; avoid colloquial terms ("bedsore," "decubitus").
— Never reverse-stage; describe healing wounds as "healing Stage X."
— Refusal of repositioning by a competent patient (pain, dyspnea, preference): document discussion of risks, alternative interventions (different surface, smaller position changes, premedication for pain), and patient understanding. Autonomy is respected, but document thoroughly.
— Family insistence on "doing everything" for a dying patient with a Kennedy terminal ulcer: reframe goals; involve palliative care; document SCALE/Kennedy designation.
— Stage 3/4 pressure ulcers in dependent adults or elders may trigger elder abuse / Adult Protective Services reporting if neglect is suspected (lack of repositioning, unsanitary conditions, contracture, multiple wounds, malnutrition, dehydration in a home or facility setting). Physicians are mandatory reporters in all US states.
— Pediatric pressure injuries in neglect contexts → child protective services.
— Stage 1 detection rates are lower in darkly pigmented skin — train staff in tactile (warmth, induration, bogginess) and comparative assessment to reduce disparity.
— Pressure ulcer status and dressing regimen must be in every transfer summary (SNF, home, rehab) — omissions are common root causes in readmissions and litigation.
Board pearl: A nursing home resident transferred to ED with a Stage 4 sacral ulcer, contractures, dehydration, and weight loss requires APS referral for suspected elder neglect — the physician is a mandatory reporter, and the presence of clinical findings, not proof of neglect, triggers the obligation.
Step 3 management: Memorize the prevention bundle: turn q2h, 30° lateral tilt, heels off bed, HOB ≤30°, pressure-redistribution mattress, skin/incontinence care, nutrition optimization, Braden documentation — this bundle answers most Step 3 prevention questions.
Key distinction: When a stem describes any chronic non-healing wound >3 months with atypical granulation or heaped edges, the answer pivots from wound care to biopsy to exclude Marjolin's ulcer (SCC).
Pressure injuries are localized ischemic and shear-mediated soft tissue damage over bony prominences or under devices that are largely preventable through systematic risk assessment, repositioning, pressure redistribution, skin and moisture care, and nutrition optimization — and that are staged by deepest visible tissue, never reverse-staged, with management escalating from offloading and moist wound care to debridement, culture-directed antibiotics for true infection, and surgical reconstruction for refractory Stage 3/4 disease.
Board pearl: If a Step 3 question gives you an immobile, malnourished, incontinent, or sensation-impaired patient — order the prevention bundle before you do anything else; if a wound already exists — stage it precisely, debride non-viable tissue (except stable heel eschar), match dressing to exudate, treat only clinical infection, optimize nutrition and offloading, and escalate to MRI/biopsy/plastics when healing stalls.