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geriatrics.pressure-injury.core.v1PRODUCTION
geriatrics.pressure-injury.core.v1

Pressure injury (staging and management)

general_internal_medicinechronicsubacutegeriatricadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm scope: localized skin/soft-tissue injury from sustained pressure +/- shear over a bony prominence or under a device; orient prevention-led vs established-injury management; clarify whether goals are curative or comfort/palliative (NPIAP/EPUAP 2019)

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Advance rule
Set
Advance when

Pressure etiology plausible and curative-vs-palliative frame set (NPIAP/EPUAP 2019)

Patient inputs (11)

Immobility / bed- or chair-bound state is the dominant modifiable driver; sets repositioning need (NPIAP/EPUAP 2019)

Incontinence-associated dermatitis is a distinct mimic and a pressure-injury accelerant; drives barrier/moisture plan (NPIAP/EPUAP 2019)

Peripheral arterial disease/ischemic limb changes debridement safety and distinguishes arterial ulcer mimic (NPIAP/EPUAP 2019)

Palliative / end-of-life context (Kennedy terminal ulcer) shifts to comfort-focused wound care (NPIAP/EPUAP 2019)

Geriatric skin fragility, thin dermis, reduced perfusion raise risk; informs goals-of-care framing at end of life

Anatomic site (sacrum/heel/ischium/trochanter) + tissue visible drives NPIAP stage assignment (NPIAP 2016 staging revision)

Malnutrition impairs healing; protein/energy and micronutrient optimisation is a core bundle element (NPIAP/EPUAP 2019)

Sensory perception, moisture, activity, mobility, nutrition, friction/shear — Braden risk stratification + clinical judgement (Braden & Bergstrom 1987)

Corticosteroids/immunosuppression/sedatives impair healing and mobility; vasopressors worsen perfusion in ICU

Nutritional/inflammatory marker trended with prealbumin; supports malnutrition screen (NPIAP/EPUAP 2019)

Fever flags spreading/systemic wound infection or sepsis from infected pressure injury

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Severity triggers (5)

5 need judgement
  • informationallife_threateningsepsis_from_infected_pressure_injury
    Sepsis arising from an infected pressure injury — qSOFA >=2 or NEWS2 high-risk with an infected Stage 3/4 wound (Sepsis-3 2016; NPIAP/EPUAP 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningnecrotizing_soft_tissue_infection
    Necrotizing soft-tissue infection complicating a pressure injury — crepitus, rapidly spreading erythema, pain out of proportion, hemorrhagic bullae, systemic toxicity (NPIAP/EPUAP 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverestage4_with_osteomyelitis
    Stage 4 pressure injury with exposed bone / positive probe-to-bone and biopsy-confirmed osteomyelitis (NPIAP/EPUAP 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererapidly_evolving_deep_tissue_injury
    Deep tissue pressure injury evolving rapidly to full-thickness loss within hours-to-days despite offloading (NPIAP/EPUAP 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatekennedy_terminal_ulcer_goals_of_care
    Kennedy terminal ulcer / skin failure at end of life — rapidly developing pear/butterfly sacral lesion in an actively dying patient (NPIAP/EPUAP 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Pressure injury — risk assessment → prevention bundle → stage-based wound care → infection mgmt → NPWT/flap → goals-of-care
axis: pressure_injury_prevention_and_stage_based_managementstep 1 - Step 1 — Risk assessment (Braden subscales + clinical judgement)
Selected step "Step 1 — Risk assessment (Braden subscales + clinical judgement)" — Every immobile/at-risk patient on admission and at routine reassessment
  • braden_risk_assessment_and_full_skin_inspection
    first line
    risk_assessment
    triggers: admission, immobility, icu, spinal_cord_injury, advanced_frailty, routine_reassessment
    NPIAP/EPUAP 2019 — structured risk tool (Braden: sensory perception, moisture, activity, mobility, nutrition, friction/shear) combined with clinical judgement plus head-to-toe skin inspection; reassess on condition change

outpatient playbook — drug actions (4)

  1. 1. braden_risk_assessment
    Structured tool + clinical judgement • assessment • each visit
    trigger: At-risk community-dwelling / home / SNF
    Recurrence-prevention intensity
  2. 2. home_prevention_bundle
    Repositioning schedule, home support surface, heel float, moisture barrier, nutrition • positioning/device • continuous at home
    trigger: At-risk
    Prevention is primary outpatient lever
  3. 3. stage_based_dressing_regimen
    Stage/exudate-matched dressings; autolytic/enzymatic debridement if non-viable tissue and not stable heel eschar • wound care • per home health schedule
    trigger: Healable established injury
    Community wound management
  4. 4. high_protein_oral_nutrition_supplement
    High-protein +/- arginine formula if Stage >=3 malnourished • PO • daily
    trigger: Malnourished with Stage >=3
    Healing substrate

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Skin breakdown / non-blanchable erythema / blister over sacrum, heel, ischium, trochanter, occiput (NPIAP/EPUAP 2019); Immobility / bedbound / ICU / spinal cord injury / advanced frailty — at-risk skin (NPIAP/EPUAP 2019); Braden Scale <=18 (mild) / <=12 (high) on admission or routine reassessment (Braden & Bergstrom 1987).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Pressure injury (staging and management)** (geriatrics.pressure-injury.core.v1).
Phenotype framing: Distinguish pressure injury from mimics by location/etiology: incontinence-associated/moisture dermatitis (perineal, no bony prominence, diffuse), arterial ulcer (distal, dry, painful, absent pulses), venous ulcer (gaiter area, exudative), diabetic neuropathic foot ulcer (plantar pressure points), skin tear, calciphylaxis, pyoderma gangrenosum; also classify pressure-injury type (Stage 1–4 / Unstageable / DTPI / device-related / mucosal) (NPIAP 2016 staging revision)
Scope: Confirm scope: localized skin/soft-tissue injury from sustained pressure +/- shear over a bony prominence or under a device; orient prevention-led vs established-injury management; clarify whether goals are curative or comfort/palliative (NPIAP/EPUAP 2019)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Pressure injury — risk assessment → prevention bundle → stage-based wound care → infection mgmt → NPWT/flap → goals-of-care** — step "Step 1 — Risk assessment (Braden subscales + clinical judgement)".
1. braden_risk_assessment_and_full_skin_inspection (risk_assessment, first line) — NPIAP/EPUAP 2019 — structured risk tool (Braden: sensory perception, moisture, activity, mobility, nutrition, friction/shear) combined with clinical judgement plus head-to-toe skin inspection; reassess on condition change

Setting playbook (outpatient) — Prevent recurrence and manage healable injuries in the community with support-surface provision, caregiver education, nutrition optimisation, and timely escalation of non-healing or infected wounds
2. braden_risk_assessment Structured tool + clinical judgement assessment each visit — At-risk community-dwelling / home / SNF (Recurrence-prevention intensity)
3. home_prevention_bundle Repositioning schedule, home support surface, heel float, moisture barrier, nutrition positioning/device continuous at home — At-risk (Prevention is primary outpatient lever)
4. stage_based_dressing_regimen Stage/exudate-matched dressings; autolytic/enzymatic debridement if non-viable tissue and not stable heel eschar wound care per home health schedule — Healable established injury (Community wound management)
5. high_protein_oral_nutrition_supplement High-protein +/- arginine formula if Stage >=3 malnourished PO daily — Malnourished with Stage >=3 (Healing substrate)

Non-pharmacologic actions:
- Home health wound care nursing referral
- DME order for pressure-redistributing mattress/cushion
- Caregiver training: repositioning, skin checks, dressing change, red-flag recognition
- Wound clinic / WOCN follow-up scheduling
- Dietitian referral
- Advance care planning discussion if frailty/terminal trajectory

AVOID / contraindication checks:
- Do_not_debride_stable_dry_intact_heel_eschar (NPIAP/EPUAP 2019)
- No_debridement_of_ischemic_limb_without_vascular_assessment (NPIAP/EPUAP 2019)
- Avoid_superficial_swab_cultures_for_diagnosis_use_deep_tissue (NPIAP/EPUAP 2019)
- No_systemic_antibiotics_for_colonised_non_spreading_ulcer (NPIAP/EPUAP 2019)
- Do_not_massage_or_vigorously_rub_bony_prominences_or_stage1_skin (NPIAP/EPUAP 2019)
- Do_not_position_patient_directly_on_the_pressure_injury (NPIAP/EPUAP 2019)
- No_npwt_over_untreated_osteomyelitis_or_undebrided_necrotic_tissue (NPIAP/EPUAP 2019)

Monitoring

Regimen monitoring:
- wound measurement and PUSH tool baseline then weekly (NPIAP/EPUAP 2019)
- braden reassessment each ICU shift or daily inpatient or each visit (Braden & Bergstrom 1987)
- nutrition markers albumin prealbumin intake weight q1-2wk (NPIAP/EPUAP 2019)
- infection surveillance local to spreading to systemic each dressing change (NPIAP/EPUAP 2019)
- support surface and repositioning adherence audit (NPIAP/EPUAP 2019)

Setting (outpatient) monitoring:
- Wound measurement + PUSH each visit (NPIAP/EPUAP 2019)
- Braden each visit (Braden & Bergstrom 1987)
- Nutrition markers + weight per dietitian (NPIAP/EPUAP 2019)
- Caregiver-reported red-flag check between visits (NPIAP/EPUAP 2019)

Follow-up plan: Care-transition skin handoff (POA documentation, stage, support surface continuity), caregiver/patient education on repositioning and skin checks, recurrence-prevention plan, dietitian follow-up, wound clinic / WOCN review, advance care planning and goals-of-care revisited at each transition; quality/never-event reconciliation for hospital-acquired Stage 3/4/Unstageable/DTPI (NPIAP/EPUAP 2019)
- Close-out criterion: Skin handoff documented, education delivered, follow-up and ACP scheduled (NPIAP/EPUAP 2019)

Monitoring phase: Wound measurement + PUSH tool at baseline then weekly (and at any deterioration); reassess Braden each shift in ICU / daily acute inpatient / each home or clinic visit; trend nutrition markers (albumin/prealbumin, intake, weight) q1–2 weeks; surveillance for local-to-spreading infection, evolving DTPI, undermining/tunneling; verify offloading and repositioning adherence (NPIAP/EPUAP 2019)

Disposition

Current setting: outpatient — Prevent recurrence and manage healable injuries in the community with support-surface provision, caregiver education, nutrition optimisation, and timely escalation of non-healing or infected wounds

Disposition criteria:
- Continue community management while healing on serial PUSH with adequate caregiver support (NPIAP/EPUAP 2019)
- Refer to inpatient/wound clinic for infection, surgical need, or failure to progress (NPIAP/EPUAP 2019)
- Transition to hospice/palliative wound care if terminal and comfort-focused (NPIAP/EPUAP 2019)

Escalation triggers (move to higher acuity):
- Spreading erythema, fever, or systemic signs → urgent in-person evaluation / ED for possible sepsis (Sepsis-3 2016)
- Non-healing Stage 3/4 after optimised care → wound clinic + plastic surgery referral (NPIAP/EPUAP 2019)
- New Unstageable lesion or rapidly evolving DTPI → expedited specialist review (NPIAP/EPUAP 2019)
- Caregiver unable to deliver prevention bundle → escalate support / consider higher level of care (NPIAP/EPUAP 2019)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Sepsis arising from an infected pressure injury — qSOFA >=2 or NEWS2 high-risk with an infected Stage 3/4 wound (Sepsis-3 2016; NPIAP/EPUAP 2019)
- [LIFE_THREATENING] Necrotizing soft-tissue infection complicating a pressure injury — crepitus, rapidly spreading erythema, pain out of proportion, hemorrhagic bullae, systemic toxicity (NPIAP/EPUAP 2019)
- [SEVERE] Stage 4 pressure injury with exposed bone / positive probe-to-bone and biopsy-confirmed osteomyelitis (NPIAP/EPUAP 2019)

Citations

- 2019 NPIAP/EPUAP/PPPIA International Pressure Ulcer/Injury Clinical Practice Guideline; 2024 updates; NPIAP 2016 staging revision [PMID:36637827](https://pubmed.ncbi.nlm.nih.gov/36637827/)
- Cited evidence (PMID 27537486) [PMID:27537486](https://pubmed.ncbi.nlm.nih.gov/27537486/)
- Cited evidence (PMID 25946386) [PMID:25946386](https://pubmed.ncbi.nlm.nih.gov/25946386/)
- Cited evidence (PMID 24080430) [PMID:24080430](https://pubmed.ncbi.nlm.nih.gov/24080430/)
- Cited evidence (PMID 32271587) [PMID:32271587](https://pubmed.ncbi.nlm.nih.gov/32271587/)

Last reconciled with current guidelines: 2026-05-16.
References
  • 2019 NPIAP/EPUAP/PPPIA International Pressure Ulcer/Injury Clinical Practice Guideline; 2024 updates; NPIAP 2016 staging revision — PMID:36637827
  • Cited evidence (PMID 27537486) — PMID:27537486
  • Cited evidence (PMID 25946386) — PMID:25946386
  • Cited evidence (PMID 24080430) — PMID:24080430
  • Cited evidence (PMID 32271587) — PMID:32271587