Pressure Injuries

Clinical Snapshot

A pressure injury (PI) — previously called a pressure ulcer, decubitus ulcer, or bedsore — is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence, caused by intense and/or prolonged pressure, or pressure combined with shear.^[1] When external pressure on tissue exceeds capillary closing pressure, blood vessels occlude, perfusion falls, and tissue necrosis follows — this can begin within roughly 1 to 6 hours of sustained, unrelieved loading over a bony prominence, and less pressure is needed to cause ischemia in a patient with impaired circulation, on a vasopressor, or with impaired oxygenation. The injured area may present as intact discoloured skin or an open wound and is staged (Stage 1 through 4, Unstageable, or Deep Tissue Injury) to describe the depth of tissue involvement at the time of assessment — staging is not used to track healing progress, since a pressure injury does not heal by reverse-staging.^[2] Pressure relief is the central intervention for both prevention and treatment: no dressing, topical agent, or systemic therapy can heal a pressure injury while the causative pressure and shear remain unaddressed.

Recognize the Condition

A pressure injury may present anywhere along a spectrum from intact but discoloured skin through full-thickness tissue loss with exposed bone. Use the National Pressure Injury Advisory Panel (NPIAP) staging system for every assessment — staging is specific to pressure injuries and should not be applied to other types of skin injury (e.g., moisture-associated skin damage, a traumatic wound, or a venous/arterial ulcer — see the comparison table in Assessment & Diagnosis).^[2]

NPIAP staging system

Pressure injuries do not necessarily progress through these stages in order, and do not heal by reverse-staging.

Stage 1 — Nonblanchable erythema of intact skin

Intact skin with a localized area of nonblanchable erythema. Blanchable erythema, or a change in sensation, temperature, or tissue firmness, may precede the visible colour change. In darkly pigmented skin, purple or maroon discolouration is not typical of Stage 1 and instead suggests a deep tissue injury.

Stage 2 — Partial-thickness skin loss with exposed dermis

The wound bed is viable, pink or red, and moist, and may present as an intact or ruptured serum-filled blister. Adipose tissue and deeper structures are not visible, and granulation tissue, slough, and eschar are not present. Do not use this stage to describe moisture-associated skin damage (incontinence-associated dermatitis, intertriginous dermatitis, medical adhesive-related skin injury) or a traumatic wound (skin tear, burn, abrasion).

Stage 3 — Full-thickness skin loss

Adipose tissue is visible in the wound; granulation tissue and rolled wound edges (epibole) are often present, and slough and/or eschar may be visible. Depth varies by anatomical location, and undermining or tunnelling may occur. Fascia, muscle, tendon, ligament, cartilage, and bone are not exposed — if slough or eschar obscures the true extent of tissue loss, classify the injury as Unstageable rather than Stage 3.

Stage 4 — Full-thickness skin and tissue loss

Exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. Slough and/or eschar may be visible, and rolled edges, undermining, and/or tunnelling often occur. If slough or eschar obscures the true extent of tissue loss, classify the injury as Unstageable rather than Stage 4.

Unstageable — Obscured full-thickness skin and tissue loss

The true depth cannot be determined because the wound bed is covered by slough or eschar; once removed, a Stage 3 or Stage 4 injury will be revealed. Stable eschar (dry, adherent, intact, without erythema or fluctuance) on an ischemic limb or the heel should not be softened or removed.

Deep Tissue Injury — Persistent nonblanchable deep discolouration

Intact or non-intact skin with a localized area of persistent nonblanchable deep red, maroon, or purple discolouration, or epidermal separation revealing a dark wound bed or blood-filled blister — visible in lighter skin tones but often very difficult to detect in darker skin tones. Pain and temperature change often precede the visible colour change. Results from intense and/or prolonged pressure and shear at the bone-muscle interface, and may evolve rapidly to reveal the true extent of injury or may resolve without tissue loss.

Medical device-related and mucosal membrane pressure injuries

A medical device-related pressure injury results from a device applied for a diagnostic or therapeutic purpose (e.g., an oxygen tube, catheter, splint, or cast), and generally conforms to the pattern or shape of the device. A mucosal membrane pressure injury occurs on a mucous membrane at a site where a medical device was used (e.g., an oral airway or urinary catheter) — because of the anatomy of mucosal tissue, these injuries cannot be staged using the skin staging system above.

Assessing pigmented skin

Blanching may not be visible in darkly pigmented skin, and its colour may differ from the surrounding skin. Instead of relying on blanching alone, look for changes in skin tone, temperature, and tissue consistency compared to adjacent skin — colour changes may be easier to identify after gently moistening the skin.

Risk Factors

Decreased mobility or activity — the most consistent independent predictor of pressure injury risk.^[3]
Impaired skin perfusion (peripheral vascular disease, hypotension, shock, vasopressor use).
Poor skin condition (dry, fragile, or previously injured skin).
Increased skin moisture from incontinence, perspiration, or wound drainage.
Older age.
Poor nutritional status, including low serum albumin or hemoglobin.
Decreased overall general health status and multiple comorbidities.
Abnormal laboratory values reflecting inflammation, infection, or poor nutrition (e.g., an abnormal white blood cell count, elevated urea).
Spinal cord injury or another condition causing sensory or motor impairment.
Critical illness, prolonged surgery, or vasopressor therapy.
Smoking.
A medical device in prolonged contact with the skin (tubing, a catheter, a splint, or a cast).
End-of-life status, where tissue tolerance for pressure can decline as part of overall physiologic decline.

Red Flags & Refer

Classic local signs of infection (erythema, edema, warmth) are frequently absent in a pressure injury even when infection is genuinely present — a change in wound pain, exudate, or odour can be the only early clue, so maintain a lower threshold to escalate than for other skin infections.

Spreading erythema, warmth, or induration extending beyond the wound margin, new or worsening fever, chills, tachycardia, hypotension, or altered mental status — signs the infection may be progressing to cellulitis, bacteremia, or sepsis.
Exposed or directly palpable bone, a sinus tract that probes to bone, or a wound that fails to heal despite a genuinely adequate, guideline-concordant care plan of several weeks — signs of underlying osteomyelitis needing imaging and specialist input.
A wound that is rapidly enlarging, deepening, or otherwise deteriorating despite correctly implemented pressure relief, débridement, and dressing selection — reassess the diagnosis, healability, and adequacy of offloading rather than simply changing the dressing again.
Disproportionate pain, rapidly advancing wound margins, skin discolouration or bullae, crepitus, or systemic toxicity out of proportion to the visible wound — signs of a necrotizing soft tissue infection, a surgical emergency requiring immediate surgical consultation.
A stage 3, 4, or unstageable injury overlying the sacrum or coccyx with new bowel or bladder dysfunction, or any wound tracking toward a joint space — warrants urgent surgical or specialist assessment.

Assessment & Diagnosis

Differentiating a pressure injury from other chronic wounds

Feature	Pressure injury	Venous ulcer	Arterial (ischemic) ulcer	Diabetic/neuropathic ulcer	Incontinence-associated dermatitis / MASD
Typical location	Over a bony prominence or under a medical device	Gaiter area, medial malleolus, lower leg	Distal — toes, dorsum of foot, lateral malleolus	Plantar surface, under a metatarsal head or other pressure point	Perineum, buttocks, skin folds — diffuse, not localized to a bony prominence
Primary cause	Unrelieved pressure and/or shear	Venous hypertension, valve incompetence	Arterial insufficiency/ischemia	Peripheral neuropathy plus repetitive pressure, often with coexisting arterial disease	Prolonged skin contact with urine, stool, sweat, or wound exudate
Wound bed/edges	Edges may be rolled (epibole); bed varies by stage (granulation, slough, or eschar)	Irregular, shallow, exudative; ruddy red wound bed	Well-demarcated, "punched-out"; pale, dry wound bed	Punched-out, surrounded by callus	Superficial, diffuse, irregular borders; may have satellite lesions if candidal
Pain	Variable; can be severe with dressing changes	Mild-moderate; worse dependent, better with elevation	Often severe; worse with elevation, better dependent	Often painless from sensory neuropathy — a key diagnostic clue	Burning, stinging
Other findings	Nonblanchable erythema or discolouration at earlier stages	Hemosiderin staining, lipodermatosclerosis, edema, varicosities	Shiny, hairless, cool skin; diminished or absent pedal pulses	Callus, loss of protective sensation, foot deformity	Erythema/maceration matching the moisture-exposure pattern

A skin tear — a traumatic separation of skin layers from shear, friction, or blunt trauma against fragile skin — is a further, easily distinguished mimic: acute onset at a known moment of trauma, an irregular wound with a visible skin flap, and no relationship to pressure over a bony prominence.

Determining healability

After identifying and addressing the cause of the wound, classify it before selecting local wound care: a healable wound has no known factor preventing healing and is managed to achieve complete closure; a nonhealable wound occurs in a patient who lacks the physical capacity to heal (e.g., uncorrectable arterial insufficiency, a malignant wound, end-of-life status) and is managed to control pain and infection risk rather than pursue closure; a maintenance wound is healable in principle but cannot currently heal because of an unaddressed patient- or system-level barrier (e.g., no access to an appropriate support surface).

Vascular assessment before débridement

Before any method of débridement on the lower extremity, assess arterial supply — palpate pedal pulses, check capillary refill, and obtain an ankle-brachial index or toe pressure where available — to rule out arterial compromise that would prevent healing after débridement.

Diagnosing infection

Diagnosis is based on the clinical picture together with culture results, not on the classic signs of cellulitis alone, since these are frequently absent. Possible clinical signs include a wound that is not healing as expected, new or worsening pain, increased exudate, and a new foul odour. If infection is suspected, obtain a quantitative wound culture using the Levine technique: clean the wound first, then apply a culture swab to about a 1 cm² area of clean wound tissue with enough pressure to express fluid from the tissue, rotating the swab over that area for about 5 seconds.^[4] A qualitative swab is not diagnostic on its own, since every pressure injury contains bacteria — heavy growth on a quantitative culture in combination with clinical signs supports the diagnosis of infection.

Treatment Targets

Prevent new pressure injuries from developing in an at-risk patient.
Achieve complete healing of a healable wound.
In a nonhealable or maintenance wound, prevent further tissue damage and control the wound rather than pursuing healing.
Manage pain associated with the wound itself and with wound-care procedures.
Prevent, recognize, and treat infection when it is present.
Preserve function and quality of life, including minimizing disruption to the patient's daily activities from the wound-care schedule.

Choose Initial Treatment

Direct treatment rule

Pressure relief is the foundation of every treatment plan

Address the source of pressure and shear first for every patient with a pressure injury, regardless of stage — implement an individualized repositioning schedule, select an appropriate support surface, and offload any causative medical device before selecting a dressing. No topical or systemic therapy heals a pressure injury while pressure remains unrelieved.

Determine healability before selecting local wound care

Classify the wound as healable, nonhealable, or maintenance (see Assessment & Diagnosis) before choosing a débridement method or dressing — this determines whether the goal is closure or symptom control.

Stage 1 injuries

Stage 1 pressure relief and preventive skin care alone are usually sufficient — protect the area from further pressure and shear, keep the skin clean and dry, and reassess; a dressing is not routinely required.

Stage 2-4 and Unstageable injuries

Local wound care — cleansing, débridement where appropriate, and a dressing matched to exudate level and wound depth — is required for stage 2-4 and unstageable injuries (see Non-Pharmacologic Treatment and Drug Tables for dressing selection).

Topical antimicrobial or antiseptic use

Do not apply a topical antimicrobial or antiseptic routinely to a clean, uninfected pressure injury — evidence does not support a benefit for routine use, and it promotes resistance and contact sensitization.^[5]

Use when locally infected a topical antimicrobial/antiseptic dressing or agent is appropriate for a wound with clinical signs of local infection, a heavy bacterial burden impeding healing, or as prophylaxis in a nonhealing or nonhealable wound at high infection risk.

Systemic antibiotics

Reserve for spreading or systemic infection — use systemic antibiotics for a pressure injury with spreading infection (cellulitis, systemic signs) or confirmed/strongly suspected osteomyelitis. Do not use systemic antibiotics for a locally infected wound without spreading or systemic signs, and do not use them as a substitute for débridement and pressure relief.

Non-Pharmacologic Treatment

Repositioning

Implement a repositioning schedule to protect intact skin and avoid placing weight directly on bony prominences.^[6] Reposition a patient who cannot reposition themselves about every 2-4 hours while in bed (adjusted for overall condition, tolerance, mobility, and the support surface in use) and about every 15 minutes while sitting. Limit head-of-bed elevation to 30 degrees or less where medically feasible, and use lifting sheets, wedges, and pillows to reposition in a way that minimizes friction and shear.

Support surfaces

A patient at high risk of a pressure injury should not remain on a standard mattress. A reactive support surface changes load distribution only in response to applied load (e.g., air, water, gel, or foam mattresses/overlays, low-air-loss mattresses, air-fluidized mattresses); an active support surface (alternating-pressure mattresses) changes load distribution with or without applied load. No single specialized surface has been shown to be clearly superior to another — select based on patient risk level, wound status, and setting.^[7]

Pressure-relieving devices

Use soft pillows or foam wedges between bony prominences (e.g., knees, ankles) and to suspend the heels off the mattress, independent of the support surface in use. Medical-grade sheepskin overlays can reduce pressure injury risk. Avoid donut-shaped seat cushions — they concentrate rather than relieve pressure.

Medical devices

Avoid positioning a patient directly onto a medical device such as tubing or a drainage system. Remove a device that is a potential source of pressure as soon as medically feasible, remove any sling not intended to remain under the patient after a transfer, and inspect the skin under a device regularly, keeping it clean and dry.

Skin care and wound cleansing

Keep intact skin clean and adequately hydrated using nonalkaline cleansers, and clean up promptly after an episode of incontinence, using a barrier product to protect skin from moisture damage. Cleanse the wound at initial assessment and at every dressing change: warm the cleansing solution to room temperature, then gently irrigate with enough solution to cover the wound surface (at least 100-150 mL, more for a larger wound) at a nontraumatic pressure — a 30-35 mL syringe with an 18- or 19-gauge angiocatheter, or a single-use 100 mL squeeze bottle, provides an appropriate irrigation pressure. Tap water, sterile normal saline, and commercial wound cleansers are all reasonable choices for most wounds; reserve an antimicrobial wound cleanser (e.g., containing acetic acid, chlorhexidine, octenidine, or polyhexamethylene biguanide) for a wound with high bacterial colonization or suspected/confirmed infection. Pat the wound and surrounding skin dry afterward to help the dressing adhere.

Dressing selection by wound characteristics

Select a secondary dressing that maintains a moist wound bed without macerating the surrounding skin, controls exudate, provides thermal stability, and minimizes trauma on removal; reassess the choice at least weekly as the wound changes.

Dressing class	Description	Best suited for	Avoid when
Alginates	Sheets or ropes of a seaweed-derived fibre with hemostatic properties; produces a characteristic odour as it absorbs exudate, which can be mistaken for infection.	Moderate-to-high exudate; local hemostasis; filling dead space in a deeper wound.	A dry wound, a narrow or deep sinus, or heavy/uncontrolled bleeding.
Foams	Adherent or nonadherent polyurethane foam, with or without an adhesive border; moisture-vapour transmission varies by product.	Low-to-moderate exudate; facilitating autolytic débridement.	A highly exudating wound needing more than once-daily dressing changes, or an ischemic nonhealable wound.
Gauze	Woven or nonwoven cotton, rayon, or polyester fabric; nonwoven is more absorbent and sheds less lint.	Low-to-high exudate; filling dead space; delivering a paste, ointment, or gel into the wound.	As the sole method for mechanical débridement (wet-to-dry) — not recommended given pain and trauma to healthy tissue on removal.
Hydrocolloids	Occlusive sheet dressing with a polyurethane outer layer, often containing gelatin, sodium carboxymethylcellulose, or pectin; also produces a characteristic odour on removal that can be mistaken for infection.	Low exudate; facilitating autolytic débridement.	Moderate-to-high exudate, an infected wound, a deep cavity, or a dry lower-limb wound with arterial insufficiency.
Hydrogels	High-water-content polymer (gel, solid sheet, or gel-impregnated gauze), sometimes containing pectin or collagen.	A dry wound with little or no exudate; facilitating autolytic débridement.	Moderate-to-high exudate, an infected wound, or a dry lower-limb wound with arterial insufficiency.
Transparent films	Transparent, semi-permeable polyurethane adhesive sheet, impermeable to liquid and bacteria; moisture-vapour transmission varies by product.	Protecting skin at risk of pressure or friction injury; a secondary dressing or device fixation; facilitating autolytic débridement.	Moderate-to-high exudate, an infected wound, or a deep cavity.

Débridement

Débridement removes devitalized tissue to allow granulation and re-epithelialization, prevent infection, and convert a chronic wound toward the environment of an acute, healing wound. Confirm adequate arterial supply before débriding a lower-extremity wound (see Assessment & Diagnosis), and do not débride stable, dry, adherent eschar on an ischemic limb or the heel unless infection is suspected. Select the method appropriate to the wound, setting, and available training: conservative sharp débridement (removing only nonviable tissue with sterile instruments, generally painless) is commonly performed at the bedside; surgical/sharp débridement (removing nonviable and some viable tissue) causes pain and bleeding and needs adequate anesthesia and, for larger amounts of tissue, an operating room; autolytic débridement uses a moisture-retentive dressing to soften and liquefy nonviable tissue over time and is painless but not recommended for an infected wound; mechanical débridement includes wound irrigation, polyacrylic microfibre pads, and low-frequency ultrasound (which disperses bacterial biofilm and can stimulate healing) — avoid wet-to-dry gauze dressings as a débridement method, since removing a dried-on dressing causes pain and traumatizes healthy tissue; enzymatic débridement uses a proteolytic agent to digest devitalized tissue and requires the wound to be kept moist to remain effective; biologic (larval) débridement is available through Health Canada's Special Access Program.

Nutrition

Assess every at-risk or affected patient for malnutrition and develop an individualized nutrition plan; involve a dietitian where available.^[8] Adequate energy and protein intake support tissue repair — a reasonable general target for a patient with an existing pressure injury is approximately 30-35 kcal/kg/day and 1.25-1.5 g/kg/day of protein, individualized to nutritional status, renal function, and overall goals of care, with a multivitamin/mineral supplement considered if dietary intake is inadequate. Evidence for any single nutritional supplement (e.g., arginine, glutamine, zinc, vitamin C) preventing or healing a pressure injury on its own is limited — treat adequate overall nutrition as the essential adjunct rather than relying on a specific supplement.

Smoking cessation

Nicotine, carbon monoxide, and hydrogen cyanide in cigarette smoke impair tissue oxygenation and delay wound healing. Encourage every patient with a pressure injury to quit smoking and refer to an appropriate cessation program or resource.

Pain, psychosocial, and financial support

Develop a patient-specific pain-management plan (see Pharmacologic Treatment Options and Drug Tables). Screen for anxiety, depression, and disrupted quality of life, and offer anxiety-reduction techniques, cognitive behavioural therapy, or a support group where appropriate; schedule wound care around important patient activities where possible, and choose a less cumbersome or lower-odour dressing (e.g., avoid a hydrocolloid dressing) when this meaningfully improves quality of life. Ask about financial barriers to dressings or medications not covered by insurance, and involve a social worker where needed.

Other adjunct wound-care therapies

Several additional therapies are used or promoted for pressure injury healing despite limited randomized trial evidence, and are considered adjuncts rather than routine care: surgical reconstruction (débridement with a skin flap) for a stage 3 or 4 injury not responding to standard care, in a patient who can tolerate anesthesia and postoperative rehabilitation; negative pressure wound therapy, which applies controlled suction to a covered wound to remove exudate and promote granulation tissue, contraindicated with untreated osteomyelitis, an untreated fistula, or proximity to major vessels; electrical stimulation, with evidence suggesting a possible benefit for healing rate but not yet sufficient to support routine use; and therapeutic ultrasound, electromagnetic therapy, ultraviolet phototherapy, hyperbaric oxygen, and anabolic steroids, none of which currently have adequate evidence to support routine use.^[1]

Pharmacologic Treatment Options

Drug / intervention	Role	Dose / use	Important adverse effects	Teaching points
Silver sulfadiazine 1% cream Special situation	Topical antimicrobial for a locally infected wound	Apply a 3-5 mm layer to the wound bed once or twice daily at each dressing change	Transient leukopenia, local burning/stinging, argyria with prolonged use	Not for routine use on a clean or uninfected wound; contraindicated under 2 months of age and near term in pregnancy; reassess the need for continued use at least every 2 weeks.
Acetaminophen Preferred	Basal analgesia for wound-related pain	325-650 mg PO/PR every 4-6 hours, scheduled or PRN, per product-specific maximum daily dose	Hepatotoxicity at supratherapeutic doses	Preferred first-line analgesic for wound pain, ahead of an NSAID, given the impact of NSAIDs on wound healing.
Morphine (immediate-release) Special situation	Breakthrough or pre-procedural analgesia for a painful dressing change or débridement	5-10 mg PO 30-60 minutes before the procedure, titrated to effect	Sedation, constipation, nausea, respiratory depression	Time the dose to precede the painful procedure rather than only scheduling around the clock; pair with a bowel regimen if used regularly.
Hydromorphone Special situation	Alternative pre-procedural analgesia, or when morphine is not tolerated	1-2 mg PO, or 0.2-0.5 mg SC/IV, 20-30 minutes before the procedure, titrated to effect	Sedation, constipation, nausea, respiratory depression	Fewer active-metabolite concerns than morphine in significant renal impairment.
Gabapentin Special situation	Neuropathic component of chronic wound pain	100-300 mg PO at bedtime initially, titrated over days to weeks; adjust for renal function	Sedation, dizziness, peripheral edema	Reserve for wound pain with clear neuropathic features (burning, shooting, allodynia) not fully controlled by acetaminophen/opioids.
Lidocaine (injectable) Special situation	Local infiltration anesthesia before sharp/surgical débridement	Infiltrate the periwound tissue immediately before the procedure, per institutional protocol and maximum weight-based dose	Local stinging on injection; rare systemic toxicity with excessive volume	Confirm no true amide-anesthetic allergy; use the lowest effective volume.
Piperacillin/tazobactam Special situation	Empiric broad-spectrum IV therapy for spreading infection or suspected osteomyelitis, pending cultures	Per institutional weight-based IV dosing	GI upset, rash, rare interstitial nephritis	Narrow to culture and sensitivity results once available; see the Diabetic Foot Infections and Bacterial Skin Infections chapters for deeper antibiotic-selection detail.
Ibuprofen Avoid	Routine wound-related pain	Not recommended for routine use	Impairs the inflammatory, proliferative, and remodelling phases of wound healing; GI, renal, and cardiovascular risk with regular use	Use acetaminophen first-line instead; if an NSAID is genuinely needed for a separate indication, use the lowest effective dose for the shortest duration.

Special Populations

Pregnancy

A pressure injury in pregnancy is uncommon but can occur with prolonged immobility (e.g., bed rest for a pregnancy complication, or a prolonged labour). Prevention and pressure-relief principles apply unchanged. If a topical antimicrobial is needed, avoid silver sulfadiazine at or near term given the theoretical kernicterus risk from sulfonamide-related bilirubin displacement. Avoid an NSAID for wound pain, particularly in the third trimester; acetaminophen remains the preferred basal analgesic.

Breastfeeding

Standard local wound care and most systemic antibiotics used for a spreading pressure-injury infection (penicillins, cephalosporins, metronidazole) are compatible with breastfeeding at usual doses. Avoid applying silver sulfadiazine directly to or near the breast/nipple area.

Pediatrics

Pressure injuries are less common in children than in adults, but medical device-related injury is an important and often predominant pattern in this age group — for example, from a pulse oximetry probe, nasal cannula, or cast — rather than the classic bony-prominence pattern. Use an appropriately sized device, pad or reposition the device site, and inspect the skin under the device regularly. Silver sulfadiazine is contraindicated in infants under 2 months of age.

Spinal cord injury

Lifetime pressure injury risk is high given the combination of immobility, sensory loss, and altered tissue tolerance. The bony-prominence pattern at risk depends on positioning (ischial tuberosities and sacrum in a seated wheelchair user; sacrum, heels, and occiput in a patient who is primarily supine) — an individualized seating and pressure-mapping assessment by occupational therapy is valuable.

Critical illness

Vasopressor use and hemodynamic instability lower the pressure threshold needed to cause tissue ischemia. Correctly implemented prevention can still be insufficient in a severely hemodynamically compromised patient — document this clearly rather than assuming a new injury reflects a prevention failure.

Palliative and end-of-life care

A pressure injury near the end of life may be genuinely nonhealable regardless of care quality, sometimes developing and deteriorating rapidly in a patient's final days to weeks. Shift the goal explicitly to comfort — pain, odour, and exudate control — rather than pursuing closure, and communicate this goal shift clearly to the patient and family so a nonhealing wound is not mistaken for inadequate care.

Renal and hepatic impairment

Adjust systemic antibiotic dosing for renal function per standard renal dosing references. Use silver sulfadiazine with caution in significant renal or hepatic impairment, since systemic sulfonamide absorption (proportional to the treated surface area) is cleared by these organs.

Older adults

Most pressure injuries occur in older adults; age itself is a contributing risk factor through thinner skin, reduced subcutaneous tissue, and multimorbidity. Review the medication list specifically for an agent that impairs wound healing (see Common Errors to Avoid and Drug Tables).

Monitoring & Follow-Up

Reassess pressure-injury risk on admission, at any transition between care settings, and with any major change in health status or mobility.
Measure and photograph the wound at every dressing change, or at least weekly, to track objective change in size, depth, and tissue type.
Do not use the staging system to track healing progress — a healing stage 4 injury does not become a "stage 3" and then a "stage 2"; use wound measurement instead.^[2]
Reassess the dressing choice at least weekly, and any time exudate volume, odour, or the surrounding skin condition changes.
Monitor nutritional status and intake regularly, particularly protein intake, and involve a dietitian for an at-risk or malnourished patient.
Reassess pain at every dressing change using a validated pain scale, and adjust pre-procedural analgesia if pain is inadequately controlled.
Watch specifically for the red-flag signs described above at every assessment, since classic infection signs are frequently blunted or absent in a pressure injury.

Treatment Failure / Next Step

Confirm pressure relief is actually being implemented as prescribed — repositioning schedule adherence, correct support surface, and true offloading of the affected area — before assuming the dressing or drug therapy has failed.
For a lower-extremity or heel wound, reassess arterial supply (pedal pulses, capillary refill, ankle-brachial index) if this was not already done.
Reassess nutritional status and intake; correct significant protein-calorie malnutrition or a micronutrient deficiency before expecting further healing progress.
Reassess for infection or a high bacterial bioburden impeding healing — obtain a quantitative wound culture (Levine technique) if not already done, and consider a topical antimicrobial/antiseptic trial if locally infected.
Reassess the débridement plan — nonviable tissue blocking the wound bed prevents healing; select or change the débridement method appropriate to the wound and setting.
Reassess the dressing choice against the current exudate level and wound depth — an overly absorbent dressing dries the wound bed, while one that is not absorbent enough macerates the surrounding skin.
Reconfirm the healability classification — a wound not progressing despite an optimized plan may genuinely be nonhealable or a maintenance wound limited by an unaddressed system-level barrier, in which case the goal should shift from healing to symptom control rather than escalating local therapy indefinitely.
Refer to a specialist wound care service, or to plastic, general, or vascular surgery, if the wound remains healable in principle but is not responding to an optimized plan, or if surgical reconstruction or an advanced adjunct therapy is being considered.

Common Errors to Avoid

Using a donut-shaped seat cushion — it concentrates rather than relieves pressure.
Using a wet-to-dry gauze dressing as a débridement method — removing the dried dressing causes pain and traumatizes healthy tissue.
Applying a topical antibiotic or antiseptic routinely to a clean, uninfected wound — no proven benefit, and it promotes resistance and sensitization.
Softening or removing stable, dry, adherent eschar on an ischemic limb or the heel — this eschar is protective; débridement here should only be considered if infection is suspected.
Using the pressure-injury staging system to monitor healing progress instead of wound measurement — staging describes worsening, not the reverse process of healing.
Missing an NSAID, a systemic corticosteroid, or another medication listed in Drug Tables as a contributor to delayed healing in a patient whose wound is not progressing as expected.
Proceeding with débridement of a lower-extremity wound without first assessing arterial supply.
Choosing a low-absorbency dressing (e.g., a hydrogel) for a heavily exudating wound, or a highly absorbent dressing (e.g., an alginate) for a dry, low-exudate wound.
Overlooking nutrition — not assessing and addressing protein-calorie status in a patient with a nonhealing wound.
Performing a painful dressing change or débridement procedure without first providing adequate anticipatory analgesia.
Assuming the absence of classic cellulitis signs (erythema, edema, warmth) rules out infection in a pressure injury — these signs are frequently absent even with true infection.

Clinical Decision Algorithm

Algorithm A — Initial assessment and pressure relief

New or at-risk pressure injury identified

Stage using NPIAP criteria (Stage 1-4, Unstageable, or Deep Tissue Injury); assess for medical device or mucosal membrane involvement

Implement pressure relief immediately, regardless of stage: repositioning schedule, appropriate support surface, offload/reposition any causative medical device

Stage 1 (intact skin)

Preventive skin care plus pressure relief alone; no dressing routinely required; reassess

Stage 2, 3, 4, or Unstageable

Proceed to local wound care — determine healability, then select débridement and dressing (Algorithm B)

Algorithm B — Local wound care: healability and dressing selection

Wound requires local care (Stage 2-4 or Unstageable)

Classify healability: healable, nonhealable, or maintenance

Nonhealable or maintenance

Goal shifts to pain control, odour/exudate control, and infection prevention rather than closure — select a comfortable, low-frequency-change dressing

Healable

Cleanse the wound; débride nonviable tissue by the method appropriate to the wound and setting (assess arterial supply first on a lower extremity)

Select a dressing by exudate level and wound depth: low exudate — hydrogel or transparent film; low-moderate exudate — foam; moderate-high exudate — alginate or foam; a deep wound or dead space — alginate rope or cavity foam

Reassess the dressing choice and wound measurement at least weekly

Algorithm C — Suspected infection

Suspected local infection: increased pain, increased or new-odour exudate, or a nonhealing wound

Obtain a quantitative wound culture (Levine technique)

Locally infected, no spreading or systemic signs

Topical antimicrobial/antiseptic dressing directly against the wound bed for a defined trial (about 2 weeks); reassess and discontinue once infection resolves

Spreading infection, systemic signs, or suspected osteomyelitis

Escalate: systemic antibiotics plus urgent reassessment; image or refer for suspected osteomyelitis — treat as a red flag

Drug Tables

How to use this table: Doses are adult doses and require patient-specific confirmation, including renal/hepatic adjustment. Select any drug name to open its complete Pharmasist Drug Database page.

Topical antimicrobials and antiseptics for a locally infected wound

Reserve for a wound with clinical signs of local infection or a heavy bacterial burden — not for routine use on a clean, uninfected wound.

Drug	Dosage / use	Adverse effects	Comments
Silver sulfadiazine 1% cream	Adults: Apply a 3-5 mm layer to the wound bed once or twice daily at each dressing change	Transient leukopenia (usually self-limiting), local burning, argyria with prolonged use	Broad-spectrum, including Pseudomonas aeruginosa. Contraindicated under 2 months of age and near term in pregnancy.
Mupirocin 2% ointment/cream	Use: Per the specific indication being treated — not for routine pressure-injury wound-bed application	Local burning, itching, rash	A topical antibiotic, not an antiseptic — appropriate for a defined localized bacterial skin infection or nasal MRSA decolonization, but not recommended for routine application to an open chronic wound; overuse promotes resistance.
Povidone-iodine or cadexomer iodine	Use: Apply or change the dressing per the specific product's directions; reassess after about 2 weeks	Local irritation; systemic iodine absorption with extensive/prolonged use	Broad-spectrum antiseptic, available as a solution or an iodine-releasing dressing. Avoid before/after radioactive iodine use, in significant thyroid disease or renal impairment, and generally avoid in pregnancy and breastfeeding.
Chlorhexidine (topical antiseptic solution)	Use: Per the specific product's directions as a cleansing or antiseptic solution	Local irritation; do not instill into a deep cavity or body space where it can be retained	Broad-spectrum antiseptic used mainly for wound/periwound cleansing rather than continuous wound-bed contact, given fibroblast cytotoxicity with prolonged direct exposure.
Polyhexamethylene biguanide (PHMB)	Use: Apply or change the impregnated dressing per its specific wear-time directions	Local irritation (uncommon)	Broad-spectrum antiseptic with relatively low tissue cytotoxicity, supplied impregnated into gauze, foam, or gel dressings rather than as a standalone product.
Medical-grade honey	Use: Apply or change the impregnated dressing per its specific wear-time directions	Local stinging on application; may increase exudate initially from its osmotic effect	Must be medical-grade (not culinary) honey; Leptospermum (manuka-type) species dressings have the most supporting evidence among honey products. Supplied impregnated into gauze, alginate, or gel dressings.
Gentian violet / methylene blue (topical antiseptic dye)	Use: Apply or change the impregnated dressing per its specific wear-time directions	Skin and clothing staining; local irritation	Broad-spectrum antimicrobial dye, supplied impregnated into some foam or gauze dressings. A different product from injectable/oral methylene blue used to treat methemoglobinemia — do not confuse the two.

Evidence note: a systematic review found insufficient evidence to recommend one topical antimicrobial or antiseptic agent over another for a pressure injury, and did not support routine topical antibiotic use.^[5]

Systemic antibiotics for spreading infection or suspected osteomyelitis

Reserve for a pressure injury with spreading infection, systemic signs, or confirmed/strongly suspected osteomyelitis — not for a locally infected wound without spreading or systemic signs. See the Diabetic Foot Infections and Bacterial Skin Infections chapters for more detailed antibiotic-selection guidance in a comparable chronic, potentially polymicrobial wound infection.

Drug	Dosage / use	Adverse effects	Comments
Piperacillin/tazobactam	Adults: Per institutional weight-based IV dosing	GI upset, rash, rare interstitial nephritis	Broad empiric IV coverage pending culture results; narrow once susceptibilities are available.
Ceftriaxone plus metronidazole	Combo (adults): ceftriaxone 1-2 g IV once daily + metronidazole 500 mg IV/PO every 8 hours	Ceftriaxone: biliary sludging, rash. Metronidazole: GI upset, metallic taste, peripheral neuropathy with prolonged use	An alternative empiric combination covering gram-negative and anaerobic organisms; add specific gram-positive/MRSA coverage per culture results and local resistance patterns.
Ciprofloxacin plus metronidazole	Combo (adults): ciprofloxacin 500-750 mg PO twice daily + metronidazole 500 mg PO three times daily	Ciprofloxacin: tendinopathy, QT prolongation, CNS effects. Metronidazole: GI upset, metallic taste	An oral step-down or alternative combination when IV access is limited; does not reliably cover MRSA or Streptococcus species — confirm coverage against culture results.
Clindamycin	Adults: 300-450 mg PO/IV every 6-8 hours	GI upset, Clostridioides difficile-associated diarrhea	An alternative for gram-positive/anaerobic coverage, including in a patient with a penicillin allergy.
Vancomycin (IV)	Adults: Per institutional weight-based/pharmacokinetic-monitored IV protocol	Nephrotoxicity, ototoxicity, infusion-related reactions	Added for confirmed or strongly suspected MRSA involvement. Dosed by weight and pharmacokinetic monitoring per institutional protocol — this is the intravenous formulation; it is a different product from the oral vancomycin capsule used for Clostridioides difficile colitis.

Analgesics for wound pain and wound-care procedures

Drug	Dosage / use	Adverse effects	Comments
Acetaminophen	Adults: 325-650 mg PO/PR every 4-6 hours, scheduled or PRN, per product-specific maximum daily dose	Hepatotoxicity at supratherapeutic doses	Preferred first-line basal analgesic for wound pain, ahead of an NSAID.
Morphine (immediate-release)	Pre-procedural, adults: 5-10 mg PO 30-60 minutes before the procedure, titrated to effect	Sedation, constipation, nausea, respiratory depression	Time the dose to precede a painful dressing change or débridement by 30-60 minutes; pair with a bowel regimen if used regularly.
Hydromorphone	Pre-procedural, adults: 1-2 mg PO or 0.2-0.5 mg SC/IV, 20-30 minutes before the procedure, titrated to effect	Sedation, constipation, nausea, respiratory depression	Alternative to morphine, including in significant renal impairment given fewer active-metabolite concerns.
Gabapentin	Adults: 100-300 mg PO at bedtime initially, titrated over days to weeks; adjust for renal function	Sedation, dizziness, peripheral edema	Reserve for a wound pain pattern with clear neuropathic features not fully controlled by acetaminophen/opioids.
Pregabalin	Adults: 25-75 mg PO twice daily initially, titrated to a typical target of 150-300 mg/day in divided doses; adjust for renal function	Sedation, dizziness, peripheral edema	Alternative to gabapentin with more predictable pharmacokinetics.
Lidocaine (injectable, local infiltration)	Adults: Per institutional protocol and maximum weight-based dose	Local stinging on injection; rare systemic toxicity with excessive volume or inadvertent intravascular injection	Infiltrate the periwound tissue immediately before sharp/surgical débridement; confirm no true amide-anesthetic allergy and use the lowest effective volume.
Ibuprofen (avoid for routine wound pain)	Not routinely recommended: Use only for a separate indication, at the lowest effective dose and shortest duration	Impairs the inflammatory, proliferative, and remodelling phases of wound healing; GI, renal, and cardiovascular risk with regular use	Use acetaminophen first-line instead; if an NSAID is genuinely needed for a separate indication, use the lowest effective dose for the shortest duration and monitor wound progress more closely.

References

Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline — The International Guideline (Fourth Edition) — National Pressure Injury Advisory Panel (NPIAP), European Pressure Ulcer Advisory Panel (EPUAP), Pan Pacific Pressure Injury Alliance (PPPIA); Cuddigan J, ed.. Staged online release, 2025
Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System — Journal of Wound, Ostomy and Continence Nursing (Edsberg LE, Black JM, Goldberg M, et al.). J Wound Ostomy Continence Nurs 2016;43(6):585-597
Pressure Injury Management: Risk Assessment, Prevention and Treatment (Fourth Edition) — Registered Nurses' Association of Ontario (RNAO). RNAO Best Practice Guideline, November 2024
The quantitative swab culture and smear: a quick simple method for determining the number of viable aerobic bacteria on open wounds — Journal of Trauma (Levine NS, Lindberg RB, Mason AD Jr, Pruitt BA Jr). J Trauma 1976;16(2):89-94
Antibiotics and antiseptics for pressure ulcers — Cochrane Database of Systematic Reviews (Norman G, Dumville JC, Moore ZEH, et al.). Cochrane Database Syst Rev 2016;4:CD011586
Repositioning for pressure injury prevention in adults — Cochrane Database of Systematic Reviews (Gillespie BM, Walker RM, Latimer SL, et al.). Cochrane Database Syst Rev 2020;6:CD009958
Best Practice Recommendations for Skin Health and Wound Management 2025 — Chapter 7: Prevention and Management of Pressure Injuries — Wounds Canada (Norton L, Parslow N, Ho C, et al.). Wounds Canada, 2025
Nutritional interventions for preventing and treating pressure ulcers — Cochrane Database of Systematic Reviews (Langer G, Wan CS, Fink A, et al.). Cochrane Database Syst Rev 2024;2:CD003216

Professional reference only. Apply clinical judgment and verify patient-specific decisions against current authoritative guidance and product information.