What are the stages of a pressure injury?

The NPIAP 2016 staging system, used in Australia and internationally, defines seven categories. Stage 1 is non-blanchable erythema of intact skin — the skin is red but unbroken; in darkly pigmented skin, colour change may be subtle. Stage 2 is partial-thickness skin loss with an exposed dermis or intact blister. Stage 3 is full-thickness loss with visible subcutaneous fat but fascia and deeper structures not exposed. Stage 4 is full-thickness loss with exposed or directly palpable fascia, muscle, tendon, ligament, or bone. Unstageable is full-thickness loss where slough or eschar obscures the depth — removing the eschar will reveal a Stage 3 or 4 wound; stable heel eschar on an ischaemic limb should not be removed. Deep Tissue Pressure Injury (DTI) is persistent non-blanchable deep red, maroon, or purple discolouration of intact or non-intact skin caused by intense pressure and shear at the bone-muscle interface — it may evolve rapidly to reveal the true extent. Medical Device-Related and Mucosal Membrane pressure injuries are additional categories for device-caused wounds; mucosal membrane injuries are not staged using the standard system.

Who is most at risk of developing a pressure injury?

Risk increases dramatically with immobility: bed-bound people, those with spinal cord injury or stroke, patients in intensive care, and people with cognitive impairment, dementia, or deep sedation who cannot request repositioning. Nutritional deficiency — particularly protein-energy malnutrition and dehydration — impairs tissue repair and increases fragility. Incontinence creates persistent moisture that macerates the epidermis, and faecal incontinence adds enzyme damage. Peripheral vascular disease, diabetes, and anaemia reduce tissue oxygen delivery. Elderly people have thinner, less elastic skin with reduced subcutaneous cushioning. The Braden Scale quantifies risk across six dimensions — Sensory perception, Moisture, Activity, Mobility, Nutrition, and Friction and Shear — with a total out of 23: scores of 15–18 indicate at-risk, 13–14 moderate risk, 10–12 high risk, and ≤9 very high risk. The single strongest predictor of a new pressure injury is a previous pressure injury. Medical devices — nasogastric tubes, oxygen tubing, urinary catheters, splints, and pulse oximeters — create device-patterned injuries that can be missed unless inspected daily.

What is the SSKIN bundle and how does it prevent pressure injuries?

SSKIN is an acronym for five interconnected prevention strategies. Surface: high-specification foam mattresses are first-line for at-risk patients; alternating-pressure mattresses are reserved for higher risk (Braden ≤12 or existing Stage 2+ injury); heel-offloading boots or foam wedges keep heels suspended. Donut or ring cushions are harmful and must be avoided — they create an ischaemic ring. Skin inspection: daily for all at-risk patients, twice daily for high-risk or existing injuries; bony prominences and all skin under medical devices must be checked; findings documented with dimensions, wound bed description, and photography with consent. Keep moving: bed-bound patients repositioned at minimum two-hourly — the 30-degree lateral tilt is preferred over 90-degree because it reduces trochanteric pressure; slide sheets or hover-mats must be used to avoid shear during transfers. Incontinence: prompt cleansing with pH-balanced cleanser (not soap and water), skin barrier creams (zinc oxide, dimethicone), and containment pads; incontinence-associated dermatitis must be distinguished from Stage 2 pressure injury as they have different aetiologies. Nutrition: 30–35 kcal/kg/day, 1.25–1.5 g protein/kg/day for at-risk or injured patients; oral nutritional supplements for malnourished patients; dietitian referral for complex cases.

How are pressure injuries treated?

Wound care begins with cleansing using saline or warm drinkable tap water — both are equivalent per Cochrane evidence; routine antiseptics are not recommended as they are cytotoxic to granulation tissue. Devitalised tissue is removed by debridement: sharp or surgical debridement is fastest; autolytic debridement using moisture-retaining dressings (hydrogel, hydrocolloid) is slower but comfortable and selective. Wet-to-dry dressings are no longer recommended — they are non-selective, painful, and impair healing. Dressings are matched to the wound: foam dressings (e.g., Mepilex, Allevyn) for most Stage 2–3 wounds with moderate exudate; hydrocolloid for shallow low-exudate wounds; hydrofibre or alginate (e.g., Aquacel, Kaltostat) for highly exudative or cavity wounds; silver or iodine dressings for locally infected wounds (two to four weeks then reassess). Negative-pressure wound therapy (NPWT) accelerates granulation and is appropriate for Stage 3 and 4 wounds, post-debridement cavities, and post-operative reconstruction — it requires specialist prescription and is contraindicated when malignancy or untreated osteomyelitis is present. Spreading cellulitis requires systemic antibiotics guided by eTG (typically di/flucloxacillin or cephalexin first-line; amoxicillin–clavulanate if sacral with faecal contamination); suspected osteomyelitis warrants MRI, bone biopsy, and prolonged targeted antibiotics.

What funding is available for wound dressings and care in Australia?

Wound dressings are generally not covered by the Medicare Benefits Schedule or the Pharmaceutical Benefits Scheme for most patients, meaning out-of-pocket cost unless specific entitlements apply. Veterans' Affairs (DVA) covers wound consumables for eligible veterans. NDIS participants can fund wound care within their plan supports, particularly under Daily Activities. My Aged Care Home Care Packages and Residential Aged Care facility funding can cover nursing visits and consumables for aged care recipients. Hospital in the Home (HITH) programs in most states fund wound management for patients who would otherwise require inpatient admission. Some Primary Health Networks fund community wound clinics, particularly in rural and remote areas. GP consultations are funded under MBS items 23, 36, and 44; care planning under GPCCMP items 965 and 967 (post-July 2025) enables team care arrangements for multidisciplinary input from a community nurse, dietitian, or podiatrist. Telehealth consultations with wound nurse specialists are increasingly available and reduce travel burden for people in rural areas.

Pressure injuries

Pressure injuries: prevention, staging, and wound care in Australian practice

By Dr HB Lo, FACRRM Reviewed 10 September 2026 17 min read

A pressure injury is localised skin and tissue damage from sustained pressure over a bony prominence, most common in immobile, elderly, or malnourished people. The NPIAP 2016 system stages injuries from Stage 1 (non-blanchable redness on intact skin) to Stage 4 (exposed bone, tendon, or muscle), plus Deep Tissue Injury and Unstageable categories. Prevention uses the SSKIN bundle targeting people with a Braden Scale score ≤18. Treatment matches dressings to wound characteristics; Stage 3–4 wounds may require negative-pressure therapy and specialist wound review.

Pressure injuries remain one of the most common preventable patient safety events in Australian healthcare settings. The Australian Commission on Safety and Quality in Health Care (ACSQHC) classifies them as a hospital-acquired complication that triggers activity-based funding adjustments, and pressure injury is a mandatory quarterly quality indicator in aged care under the National Aged Care Mandatory Quality Indicator Program. Despite decades of evidence-based prevention guidelines, prevalence in Australian acute care settings ranges from 0.8% to 3.6%, and in residential aged care from 3% to 12%, with under-reporting contributing to underestimates. ATSI patients and those in rural and remote settings face additional barriers to pressure-redistributing equipment and wound specialist access. The GP role spans assessment and risk stratification, prescribing evidence-based prevention, wound management in the community, and coordination of referrals for complex or non-healing injuries.

A. Core clinical — staging, risk assessment, and common sites

Definition and pathophysiology

A pressure injury (NPIAP 2016 terminology, replacing “pressure ulcer”) is localised damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device, resulting from intense or prolonged pressure or pressure in combination with shear. The core mechanism is capillary occlusion: sustained interface pressure above 32 mmHg impairs perfusion, leading to ischaemia, cellular hypoxia, and tissue necrosis. Reperfusion injury occurs on load relief. Shear forces — for example when a patient slides down a head-elevated bed — cause deep microcirculatory damage disproportionate to surface pressure. Moisture (incontinence, sweat, wound exudate) degrades the epidermal barrier and increases friction coefficient.

Common sites

Supine: sacrum and coccyx (most common), heels (highest risk for DTI), occiput, scapulae, elbows.
Side-lying: greater trochanter, lateral malleolus, lateral knee, ear, acromion.
Sitting: ischial tuberosities, sacrum, heels.
Prone (ICU): anterior chest, iliac crests, anterior knees, dorsum of feet, forehead, chin.
Medical device: nares and ear (nasogastric tube), lips (endotracheal tube), ear helix (oxygen tubing), urethra and labia (urinary catheter), toes and fingers (pulse oximeter), skin under plasters, splints, anti-embolism stockings, and C-collars.

NPIAP 2016 staging system

Stage 1 — Non-blanchable erythema of intact skin Intact skin with localised non-blanchable redness. In darkly pigmented skin, colour changes may be subtle; assess for persistent temperature change, firmness, or altered sensation. May be painful, warm, or oedematous.

Stage 2 — Partial-thickness skin loss with exposed dermis Wound bed is pink or red and moist; may present as an intact or ruptured serum-filled blister. Fat and deeper tissue are not visible. Granulation tissue, slough, and eschar are absent. Do not use this stage to describe moisture-associated skin damage (incontinence-associated dermatitis, intertriginous dermatitis, medical adhesive-related skin injury) or traumatic wounds.

Stage 3 — Full-thickness skin loss Full-thickness loss with visible subcutaneous fat. Granulation tissue and rolled wound edges (epibole) are often present. Slough or eschar may be visible. Depth varies by anatomy — areas of significant adiposity can develop deep Stage 3 wounds. Undermining and tunnelling may occur. Fascia, muscle, tendon, ligament, and bone are not exposed.

Stage 4 — Full-thickness skin and tissue loss Full-thickness loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. Epibole, undermining, and tunnelling frequently occur. Osteomyelitis is a significant complication.

Unstageable — Obscured full-thickness loss Full-thickness loss where the extent cannot be confirmed because the base is obscured by slough or eschar. Remove the slough to stage (reveals Stage 3 or 4). Exception: stable, dry, adherent eschar on the heel or ischaemic limb must not be removed — it acts as a biological cover and removal risks catastrophic wet gangrene.

Deep Tissue Pressure Injury (DTI) Intact or non-intact skin with persistent non-blanchable deep red, maroon, or purple discolouration; or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede visible colour changes. Results from intense pressure and shear at the bone-muscle interface. May resolve without tissue loss or evolve rapidly to reveal Stage 3 or 4 injury over days.

Medical Device-Related Pressure Injury Caused by a medical device; conforms to general staging; wound pattern matches the device.

Mucosal Membrane Pressure Injury Found on mucous membranes (mouth, vagina, rectum, urethra) from medical device use. Standard staging does not apply because mucous membranes lack dermis and epidermis.

Risk assessment

Braden Scale is the most validated tool (Pan Pacific Guideline 2019):

Domain	What it assesses
Sensory perception	Ability to respond to pressure-related discomfort
Moisture	Degree to which skin is exposed to moisture
Activity	Degree of physical activity
Mobility	Ability to change and control body position
Nutrition	Usual food intake pattern
Friction and shear	Degree of friction and shear with movement

Total score /23: 19–23 = no risk; 15–18 = at risk; 13–14 = moderate; 10–12 = high; ≤9 = very high. A score ≤18 triggers escalated prevention measures.

Waterlow Scale (UK origin, widely used in Australian hospitals) is an alternative; ≥10 indicates risk.

Clinical judgement must supplement scales — particularly for patients at risk from medical devices who may score low on standard measures.

Reassessment frequency: on admission; with any change in condition; daily for ICU and high-risk patients; weekly for stable patients in residential aged care.

B. Prevention — the SSKIN bundle

The Pan Pacific Guideline 2019 endorses a multi-component prevention strategy. SSKIN is the most widely adopted Australian implementation framework (Wounds Australia).

S — Surface (pressure redistribution)

High-specification foam mattresses — first-line for all at-risk inpatients; superior to standard hospital mattresses per Cochrane (McInnes 2018).
Alternating-pressure air mattresses (APAM) — for higher risk (Braden ≤12 or existing Stage 2+ injury); not consistently superior to high-spec foam but preferred when skin is very fragile or injury is progressing.
Low-air-loss mattresses — manage microclimate (temperature and humidity); particularly useful for bariatric patients and profusely incontinent patients.
Heel offloading — foam boots, pillows, or fibre-filled devices to suspend heels completely free of the mattress surface; heel is the highest-risk site for DTI and limb loss.
Seating cushions — foam, gel, air, or hybrid; reassess when posture or body weight changes.
Prophylactic multilayer foam dressings applied to the sacrum and heels in high-risk surgical and ICU patients — meta-analyses and RCTs show significant reduction in incidence.
Avoid donut or ring cushions — they create an ischaemic pressure ring at the wound perimeter; contraindicated.

S — Skin inspection

Daily for at-risk patients; twice daily for high-risk or existing injuries.
Inspect all bony prominences and under every medical device.
Document in the clinical record: location, stage, length × width × depth (mm), wound bed (% granulation/slough/eschar), exudate volume and character, peri-wound skin condition, pain score, and odour.
Photography with consent at baseline and serially — photograph as close and perpendicular to the wound as possible with scale reference.
Use the PUSH tool (Pressure Ulcer Scale for Healing, score 0–17) to track trajectory over time.

K — Keep moving (repositioning)

Bed-bound patients: minimum 2-hourly repositioning; individualise based on risk level, available surface, and haemodynamic stability.
The 30-degree lateral tilt is preferred over 90-degree lateral as it reduces pressure on the greater trochanter by approximately 40%.
Head of bed above 30 degrees increases sacral and coccygeal shear — minimise to that clinically required (e.g., aspiration precautions); use knee gatch (raising the foot end) to prevent downward slide.
Chair-bound patients: major repositioning at least hourly; 15-minute weight shifts (small shifts) if the patient can initiate; assess if the patient can perform weight-relief themselves.
Slide sheets, hover-mats, and ceiling hoists during all transfers and repositioning — this is the primary intervention to reduce shear injuries to the epidermis.
Bed positioning devices such as foam wedges to maintain the 30-degree tilt between repositioning episodes.

I — Incontinence and moisture management

Continence assessment and structured toilet schedule — incontinence is not inevitable; manage the underlying cause where possible.
Cleanse immediately after incontinence with a pH-balanced no-rinse skin cleanser (avoid soap, which disrupts the acid mantle and impairs barrier function).
Skin barrier products — zinc oxide paste, dimethicone spray, petrolatum-based products, or polymer skin sealants — applied after cleansing to protect against further moisture damage.
Distinguish incontinence-associated dermatitis (IAD) from Stage 2 pressure injury: IAD is typically bilateral, distributed along moisture-contact areas (inner thighs, perineum, buttocks crease), has an irregular shape, and is caused by chemical irritation rather than pressure. Treatment differs; IAD does not require pressure relief to resolve.
Containment products (pads, condom catheters) to reduce exposure; minimise indwelling urinary catheters to medically indicated use — catheter-associated urinary tract infection is a competing harm.

N — Nutrition

Nutritional screening (Mini Nutritional Assessment [MNA] or Malnutrition Universal Screening Tool [MUST]) on admission and with change in condition.
Energy: 30–35 kcal/kg/day for at-risk or injured patients.
Protein: 1.25–1.5 g/kg/day for at-risk or injured patients; increases to 1.5–2 g/kg/day for Stage 3–4 wounds.
Hydration: approximately 30 mL/kg/day; dehydration substantially increases risk.
Micronutrients: correct documented deficiencies — zinc, vitamin C, vitamin A, iron. Megadose supplementation in non-deficient patients has no benefit and excess zinc impairs copper absorption.
Oral nutritional supplements (ONS) — Cochrane (Langer 2014) demonstrated ONS supplementation reduces pressure injury incidence in malnourished at-risk populations; specialised wound-healing formulas containing arginine, glutamine, and zinc are available.
Dietitian referral for complex, non-healing, or clearly malnourished patients.

Education

Structured education for patients, families, carers, and residential aged care facility staff is an independent intervention associated with reduced incidence — particularly important for people with spinal cord injury and their caregivers who manage prevention at home long-term.

C. Wound assessment and management

Wound assessment — TIME/TIMERS framework

Letter	Dimension	Key questions
T — Tissue	Wound bed composition	% granulation (red), slough (yellow), eschar (black/brown), epithelium (pink); necrosis
I — Infection/Inflammation	Biofilm or infection	Increased exudate, friable granulation, persistent slough, delayed healing, wound pain, malodour, discolouration
M — Moisture balance	Exudate level	Too dry (wound desiccation) vs too wet (periwound maceration)
E — Edge	Epithelialisation	Rolled epibole; undermining; tunnelling; distance advancing vs stalled
R — Repair/Regeneration	Healing progress	Is the wound reducing in size and volume over time?
S — Social/Systemic	Patient-level factors	Nutrition, mobility, social support, access to care, palliative context

Wound cleansing

Normal saline or warm drinkable tap water — both are equivalent (Cochrane evidence); use warm (body-temperature) water to avoid hypothermia-related vasoconstriction.
Irrigation pressure — gentle irrigation (8–15 psi) to remove surface debris without damaging granulation tissue; approximate with a 35 mL syringe and 19G needle.
Routine antiseptics (chlorhexidine, povidone-iodine, hydrogen peroxide) are not recommended for non-infected wounds — they impair fibroblast activity and retard healing. Reserve for wound infection management as a short course (two to four weeks) alongside antimicrobial dressings.

Debridement

Removing devitalised tissue accelerates wound healing and reduces infection risk.

Sharp/surgical debridement — scalpel or scissors; fast and effective; requires training; appropriate for large necrotic loads. Exception: stable dry heel eschar in peripheral ischaemia — do not debride; refer to vascular surgery.
Conservative sharp debridement — bedside removal of loosely attached necrotic tissue by trained nurse or GP; widely practised in Australian community settings.
Autolytic debridement — moisture-retaining dressings (hydrogel, hydrocolloid) allow endogenous enzymes to selectively liquefy slough; slow (days to weeks) but comfortable and selective; safe for most patients.
Enzymatic debridement — collagenase ointment; limited availability in Australia; specialist use.
Mechanical debridement — monofilament fibre pads, ultrasonic wound debridement; increasing adoption in specialist wound clinics. Wet-to-dry dressings are abandoned — non-selective, painful, and associated with delayed healing; not consistent with current Pan Pacific or eTG guidelines.
Biological/larval debridement — sterile Lucilia sericata larvae selectively debride slough; limited Australian availability; specialist-initiated.

Dressings — match to wound characteristics

Wound characteristics	Recommended dressing options
Stage 1 — intact skin	Moisturiser + transparent film for protection; primary intervention is pressure relief
Stage 2 — shallow, low exudate	Hydrocolloid (DuoDERM, Comfeel); thin polyurethane film; change at 3–7 days
Stage 2/3 — moderate exudate	Foam (Mepilex, Allevyn); most versatile and widely available; change at 3–5 days
Stage 3/4 — high exudate	Hydrofibre (Aquacel) or alginate (Kaltostat) backed by foam; change 1–3 days depending on strike-through
Slough — autolytic debridement	Hydrogel (Intrasite, Aquaform) donates moisture; cover with foam or film; change at 1–3 days
Stable heel eschar	Leave intact and dry; protect; do not debride if ischaemia present
Cavity/undermining/tunnelling	Loosely pack with hydrofibre or alginate strips to absorb; avoid tight packing — it increases pressure
Local wound infection	Silver foam (Mepilex Ag, Aquacel Ag), iodine (Inadine, Iodosorb), honey (Medihoney), PHMB; maximum two to four weeks then reassess
NPWT (Stage 3/4 or post-debridement)	Specialised indication — see below
Stage 4 with bone/tendon exposure	Specialist wound or plastic surgery referral; may require debridement, flap, or graft

Dressing frequency is guided by exudate level; foam dressings are typically changed every three to five days; alginate and hydrofibre every one to three days; NPWT every two to three days.

Peri-procedural analgesia — pressure injury dressing changes can be significantly painful. Administer regular analgesia 30 minutes before dressing changes; consider topical anaesthetic gel for procedural pain (specialist); use atraumatic silicone-backed dressings (e.g., Mepilex Border) in fragile skin.

Negative-Pressure Wound Therapy (NPWT)

NPWT applies sub-atmospheric pressure (typically −125 mmHg) via a foam or gauze interface connected to a sealed dressing and a suction unit. Mechanisms: promotes granulation tissue formation, removes excess exudate, reduces periwound oedema, draws wound edges together.

Indications: Stage 3 and 4 wounds; deep cavities post-debridement; dehisced surgical wounds; pre-surgical preparation of wounds for flap or graft; selected diabetic foot ulcers.

Contraindications: malignancy in or directly adjacent to wound; untreated osteomyelitis; exposed major vessels, nerves, or organs; fistula to body cavity; dry necrotic eschar (debride first or use autolytic).

NPWT systems are available through hospital procurement, HITH programs, and wound specialist clinics. Rental cost is a significant consideration in community settings.

Infection management

Biofilm / local infection (increased exudate, friable granulation, delayed healing, odour, discoloured granulation): antimicrobial dressing (silver, iodine-based, honey, PHMB) for a defined course of two to four weeks; reassess.
Spreading cellulitis (surrounding erythema >2 cm, warmth, induration, fever, raised CRP/WBC): systemic antibiotics per eTG wound management; first-line dicloxacillin or flucloxacillin 500 mg four times daily, or cephalexin 500 mg four times daily; broaden to amoxicillin–clavulanate for sacral wounds with heavy faecal contamination or Gram-negative concern.
Osteomyelitis (bone visible or palpable at wound base, non-healing Stage 4, probe-to-bone positive, X-ray periosteal reaction or bone destruction, MRI bone marrow signal change): bone biopsy for definitive microbiological diagnosis; prolonged targeted antibiotics (minimum six weeks); vascular surgery or orthopaedic input for surgical debridement or amputation.

D. Australian operations

Funding and access

Medicare Benefits Schedule (MBS):

GP attendance: 23 (short consultation), 36 (standard), 44 (long) — wound assessment and management.
GP Comprehensive Care Management Plan (GPCCMP): 965/967 (post-July 2025) — enables Team Care Arrangements for community nurse, dietitian, and podiatrist referrals; replaces the former GPMP/TCA items 721/723.
Practice nurse wound care in chronic disease context: 10996/10997.
ATSI annual health assessment: 715 — includes skin assessment for pressure injury.
Telehealth: wound specialist photo/video review increasingly available for rural and remote patients.

Wound dressings are generally NOT funded by MBS or PBS for most patients. Out-of-pocket funding applies unless:

DVA card holders — wound consumables fully covered via DVA Community Nursing.
NDIS participants — within plan supports under Daily Activities.
My Aged Care — Home Care Package (HCP) — nursing visits and consumables.
Residential Aged Care Facility (RACF) — funding within facility-level aged care.
Hospital in the Home (HITH) — state-funded programs for complex wound management avoiding inpatient admission.
PHN-funded community wound clinics — availability varies by PHN region; concentrated in major metropolitan areas and some rural centres.
Private health insurance — ancillary cover varies; rarely includes consumables.

PBS: Systemic antibiotics for cellulitis and osteomyelitis (flucloxacillin, cephalexin, amoxicillin–clavulanate, metronidazole, ciprofloxacin — general schedule or restricted/streamlined); analgesics (paracetamol general schedule, opioids restricted); silver dressings and NPWT products are NOT PBS-listed.

Australian aged care quality framework

National Aged Care Mandatory Quality Indicator Program (QI Program): Pressure injury is one of twelve mandatory quality indicators. Residential aged care facilities must report quarterly to the Department of Health on new pressure injuries, stage, and number of residents affected. Results are publicly reported and benchmarked. This framework was expanded from 2023 to include Stage 1–4 and Unstageable injuries.

Aged Care Quality Standards: Standard 5 (Personal and Clinical Care) requires evidence of pressure injury prevention protocols, risk assessment, and documentation of management plans. The Aged Care Quality and Safety Commission assesses compliance and can require a performance improvement plan.

Hospital framework: ACSQHC Hospital-Acquired Complication (HAC) — pressure injuries Stage 2 and above acquired during the hospital admission attract activity-based funding adjustments. NSQHS Standard 5 (Comprehensive Care) requires documented pressure injury prevention for all admitted patients. Hospital-acquired pressure injuries must be distinguished from present-on-admission (POA) injuries — daily skin inspection on admission and documentation is essential for appropriate attribution.

Community wound services

Community nursing — RDNS, Bolton Clarke, Silver Chain, and state-funded services provide wound dressings in home and RACF settings; funded by DVA, HCP, and HITH.
Wound specialist clinics — public hospital outpatient wound clinics and private nurse-led services; availability concentrated in metropolitan areas.
Wound Clinical Nurse Consultants (CNCs) — hospital-based and community CNCs provide specialist guidance and coordinate complex management.
Wound Specialist Nurses — accredited by Wounds Australia (NZWCS and WACA certifications); increasing availability in general practice teams.

E. Special populations

Spinal cord injury: Lifelong, daily, highly individualised pressure injury prevention management. Incidence of lifetime pressure injury in spinal cord injury exceeds 80%. Specialist spinal injury unit care, specialised seating and wheelchair cushions, and regular pressure injury management reviews are required. Recurrence risk after surgical repair is high — approximately 30–50% within 12 months — making prevention primary. Coordinate with SCI rehabilitation centres; most states have specialised outreach services.

Palliative care and end of life: Skin failure — including pressure injury development — is recognised at end of life. The SCALE (Skin Changes At Life’s End) consensus acknowledges that pressure injuries may develop in the final days to hours despite optimal prevention, and are not necessarily attributable to care failure. The Kennedy terminal ulcer — a butterfly-shaped sacral wound of sudden onset, typically in the final days of life, progressing rapidly — is a recognised end-of-life phenomenon. In palliative context, the care goal shifts to symptom control and comfort: wound odour management (charcoal dressings, Medihoney), pain control with pre-medication before dressing changes, and family education. Atraumatic dressings minimise distress. Do not use aggressive debridement or NPWT where cure is not the goal.

Bariatric patients: Require specialised high-weight-capacity beds (minimum 250–500 kg rating), bariatric alternating-pressure mattresses, and wide seating with appropriate cushioning. Skin folds — particularly beneath the pannus, beneath breasts, and in the groin — are high-moisture areas requiring daily cleansing and skin barrier protection. HITH programs and NDIS may fund equipment hire.

Paediatric and neonatal patients: Neonates in NICU are at high risk — particularly preterm infants with thin, gelatinous skin; and neonates with medical devices (CPAP nasal prongs, IV splints, sensor probes). The Glamorgan Scale is validated for paediatric risk assessment. Smaller pressure-redistributing surfaces (gel mattress overlays, neonatal foam mattresses) are needed. Medical device rotation and padding are the principal interventions.

Critical care: Haemodynamic instability may limit the frequency or extent of repositioning — clinical judgement must balance pressure injury prevention against cardiovascular stability. Prone positioning, used in acute respiratory distress syndrome management, creates high-risk areas on the face, chest, genitalia, and feet that require vigilant inspection and prophylactic dressings before turning.

When to escalate

Emergency — same day hospital referral: Suspected osteomyelitis (bone visible or palpable, probe-to-bone positive, systemic sepsis with a deep wound); spreading cellulitis with systemic illness (fever, rigors, hypotension); critical ischaemia with impending limb loss; wound-related bacteraemia.

Urgent specialist referral: Stage 4 or large Stage 3 wounds not progressing despite three to four weeks of optimised treatment; suspected osteomyelitis without systemic illness (MRI for confirmation); suspected malignant transformation of a chronic wound (Marjolin’s ulcer); complex cavity with suspected fistula; spinal cord injury wound; wounds requiring plastic surgery assessment for flap or graft.

Routine wound specialist/CNC review: Any wound that has not reduced by 20–30% in size after two to four weeks of appropriate treatment; wounds requiring NPWT initiation; complex dressing decisions; bariatric patients requiring equipment sourcing; carer education or home-environment assessment needs.

Dietitian referral: Clinically malnourished patients (MNA or MUST score indicating moderate or severe malnutrition); any Stage 3 or 4 wound; non-healing wounds despite standard care; unintentional weight loss exceeding 5% in one month or 10% in six months.

What this article is and is not

This article provides educational information about pressure injuries for patients, carers, and clinicians. It is not a substitute for individualised clinical assessment and wound management planning. Wound care decisions — including debridement method, dressing selection, antibiotic choice, and surgical referral — require assessment of the individual wound, the patient’s overall medical context, their goals of care, and access to services. Patients in residential aged care or hospital settings should receive care according to their facility’s pressure injury prevention and management protocols. Complex or non-healing wounds should be assessed by a wound specialist or wound CNC.

Sources cited

Frequently asked questions

What are the stages of a pressure injury?

The NPIAP 2016 staging system, used in Australia and internationally, defines seven categories. Stage 1 is non-blanchable erythema of intact skin — the skin is red but unbroken; in darkly pigmented skin, colour change may be subtle. Stage 2 is partial-thickness skin loss with an exposed dermis or intact blister. Stage 3 is full-thickness loss with visible subcutaneous fat but fascia and deeper structures not exposed. Stage 4 is full-thickness loss with exposed or directly palpable fascia, muscle, tendon, ligament, or bone. Unstageable is full-thickness loss where slough or eschar obscures the depth — removing the eschar will reveal a Stage 3 or 4 wound; stable heel eschar on an ischaemic limb should not be removed. Deep Tissue Pressure Injury (DTI) is persistent non-blanchable deep red, maroon, or purple discolouration of intact or non-intact skin caused by intense pressure and shear at the bone-muscle interface — it may evolve rapidly to reveal the true extent. Medical Device-Related and Mucosal Membrane pressure injuries are additional categories for device-caused wounds; mucosal membrane injuries are not staged using the standard system.
Who is most at risk of developing a pressure injury?

Risk increases dramatically with immobility: bed-bound people, those with spinal cord injury or stroke, patients in intensive care, and people with cognitive impairment, dementia, or deep sedation who cannot request repositioning. Nutritional deficiency — particularly protein-energy malnutrition and dehydration — impairs tissue repair and increases fragility. Incontinence creates persistent moisture that macerates the epidermis, and faecal incontinence adds enzyme damage. Peripheral vascular disease, diabetes, and anaemia reduce tissue oxygen delivery. Elderly people have thinner, less elastic skin with reduced subcutaneous cushioning. The Braden Scale quantifies risk across six dimensions — Sensory perception, Moisture, Activity, Mobility, Nutrition, and Friction and Shear — with a total out of 23: scores of 15–18 indicate at-risk, 13–14 moderate risk, 10–12 high risk, and ≤9 very high risk. The single strongest predictor of a new pressure injury is a previous pressure injury. Medical devices — nasogastric tubes, oxygen tubing, urinary catheters, splints, and pulse oximeters — create device-patterned injuries that can be missed unless inspected daily.
What is the SSKIN bundle and how does it prevent pressure injuries?

SSKIN is an acronym for five interconnected prevention strategies. Surface: high-specification foam mattresses are first-line for at-risk patients; alternating-pressure mattresses are reserved for higher risk (Braden ≤12 or existing Stage 2+ injury); heel-offloading boots or foam wedges keep heels suspended. Donut or ring cushions are harmful and must be avoided — they create an ischaemic ring. Skin inspection: daily for all at-risk patients, twice daily for high-risk or existing injuries; bony prominences and all skin under medical devices must be checked; findings documented with dimensions, wound bed description, and photography with consent. Keep moving: bed-bound patients repositioned at minimum two-hourly — the 30-degree lateral tilt is preferred over 90-degree because it reduces trochanteric pressure; slide sheets or hover-mats must be used to avoid shear during transfers. Incontinence: prompt cleansing with pH-balanced cleanser (not soap and water), skin barrier creams (zinc oxide, dimethicone), and containment pads; incontinence-associated dermatitis must be distinguished from Stage 2 pressure injury as they have different aetiologies. Nutrition: 30–35 kcal/kg/day, 1.25–1.5 g protein/kg/day for at-risk or injured patients; oral nutritional supplements for malnourished patients; dietitian referral for complex cases.
How are pressure injuries treated?

Wound care begins with cleansing using saline or warm drinkable tap water — both are equivalent per Cochrane evidence; routine antiseptics are not recommended as they are cytotoxic to granulation tissue. Devitalised tissue is removed by debridement: sharp or surgical debridement is fastest; autolytic debridement using moisture-retaining dressings (hydrogel, hydrocolloid) is slower but comfortable and selective. Wet-to-dry dressings are no longer recommended — they are non-selective, painful, and impair healing. Dressings are matched to the wound: foam dressings (e.g., Mepilex, Allevyn) for most Stage 2–3 wounds with moderate exudate; hydrocolloid for shallow low-exudate wounds; hydrofibre or alginate (e.g., Aquacel, Kaltostat) for highly exudative or cavity wounds; silver or iodine dressings for locally infected wounds (two to four weeks then reassess). Negative-pressure wound therapy (NPWT) accelerates granulation and is appropriate for Stage 3 and 4 wounds, post-debridement cavities, and post-operative reconstruction — it requires specialist prescription and is contraindicated when malignancy or untreated osteomyelitis is present. Spreading cellulitis requires systemic antibiotics guided by eTG (typically di/flucloxacillin or cephalexin first-line; amoxicillin–clavulanate if sacral with faecal contamination); suspected osteomyelitis warrants MRI, bone biopsy, and prolonged targeted antibiotics.
What funding is available for wound dressings and care in Australia?

Wound dressings are generally not covered by the Medicare Benefits Schedule or the Pharmaceutical Benefits Scheme for most patients, meaning out-of-pocket cost unless specific entitlements apply. Veterans' Affairs (DVA) covers wound consumables for eligible veterans. NDIS participants can fund wound care within their plan supports, particularly under Daily Activities. My Aged Care Home Care Packages and Residential Aged Care facility funding can cover nursing visits and consumables for aged care recipients. Hospital in the Home (HITH) programs in most states fund wound management for patients who would otherwise require inpatient admission. Some Primary Health Networks fund community wound clinics, particularly in rural and remote areas. GP consultations are funded under MBS items 23, 36, and 44; care planning under GPCCMP items 965 and 967 (post-July 2025) enables team care arrangements for multidisciplinary input from a community nurse, dietitian, or podiatrist. Telehealth consultations with wound nurse specialists are increasingly available and reduce travel burden for people in rural areas.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.