Prevention and Management of Pressure Injuries and Lower Extremity Ulcers
Pressure injuries
Risk assessment (Braden or Norton) plus skin inspection at every encounter. Prevention includes individualized repositioning, pressure-redistributing support surfaces, heel offloading, keeping the head of bed at or below 30 degrees when possible, moisture management, and nutrition support. Avoid massaging bony prominences.
Staging applies only to pressure injuries: Stage 1 nonblanchable erythema with intact skin; Stage 2 partial-thickness loss with dermis exposed (shallow open ulcer or intact/ruptured blister); Stage 3 full-thickness loss with fascia, subcutaneous fat, granulation, or slough visible, but no bone, tendon, or muscle; Stage 4 full-thickness with exposed bone, tendon, muscle, or joint; unstageable when slough or eschar obscures the bed; deep tissue pressure injury persistent nonblanchable deep red, maroon, or purple skin change. Mucosal membranes and medical device injuries are classified separately, not staged, and injuries never "reverse stage" as they heal.
Lower extremity ulcers
Venous ulcers: compression (commonly 30–40 mmHg at the ankle), elevation, exercise, and edema control, after confirming adequate arterial perfusion. Arterial ulcers: revascularization is the definitive treatment; compression is contraindicated in severe ischemia. Neuropathic/diabetic foot ulcers: offloading (total contact cast or irremovable device when appropriate), glucose control, and regular foot inspection. Mixed venous-arterial disease requires modified compression based on ankle-brachial index.
Traps
- Staging an arterial ulcer, or reverse staging a healing pressure injury.
- Applying high compression when the ankle-brachial index is low.
- Calling a wound "stage 3" when eschar obscures the depth.
Rule of thumb
No stage without a pressure injury; no compression without a perfusion check; no neuropathic ulcer healing without offloading.