Pressure Ulcer Prevention, NPIAP/EPUAP Staging & Skin Integrity
From early warning signs and international grading criteria to repositioning schedules, dressing selection, and NICE-aligned prevention — everything you need to protect skin and report safely.
Pressure ulcers — also called pressure sores or bedsores — are one of the clearest measures of nursing care quality. They are painful, preventable, and can lengthen hospital stays, cause life-threatening infection, and severely affect a patient’s confidence and wellbeing. For you as a student nurse, skin integrity work is not just “basic care” — it is skilled, evidence-based practice that demands your attention every single shift.
What starts as a faint red patch can break down deeply within hours, often damaging tissue before it is even visible on the surface. Prevention is always better — and far easier — than the cure. This guide follows the UK national standard: NICE CG179: Pressure Ulcers — Prevention and Management and the international NPIAP/EPUAP staging framework.
1. What Actually Destroys Skin? The Three Forces
Three mechanical forces work together to cut off blood supply and kill tissue. Understanding them is the first step to stopping them:
| Force | What It Means | What It Looks Like on the Ward |
|---|---|---|
| Pressure | Weight presses soft tissue between bone and bed, squashing capillaries shut. Blood cannot get through — tissue starves. | Lying still on your back for 2+ hours; sacrum bears the full weight. Capillary closing pressure is ~32 mmHg — mattress weight easily exceeds this. |
| Shear | Skin stays still against sheets while deeper bone and tissue slide downward — blood vessels stretch and tear internally. | Sitting up too steeply in bed — your body slides down but skin sticks. Deep damage happens before surface signs appear. |
| Friction | Skin rubs against bedding or clothing, stripping away the protective outer layer. | Pulling someone up in bed without slide sheets. Leaves skin raw, vulnerable, and prone to breakdown. |
Blood flow can drop dangerously within 1–2 hours of unrelieved pressure. The worst damage often starts deepest, nearest the bone — so by the time you see a mark on the skin, harm may already be well established.
2. NPIAP/EPUAP Pressure Ulcer Staging — Clear Guide
Accurate staging ensures everyone speaks the same language. These categories are used worldwide and are the standard for all UK trusts:
Stage 1 — Non-Blanchable Erythema
Intact skin with redness that does not fade when you press it with a finger. May feel warmer, firmer, or different in sensation compared to surrounding skin. Reversible if pressure is fully removed immediately.
Stage 2 — Partial-Thickness Loss
Shallow open wound — pink/red bed, no slough. May look like a blister (intact or burst). Top layers of skin lost but fat and deeper tissue not visible. Caused by pressure or moisture damage.
Stage 3 — Full-Thickness Skin Loss
Subcutaneous fat visible — deep crater. Bone, tendon, or muscle not showing. Slough may be present. Can have undermining or tunneling around edges. Damage reaches down to but not through underlying fascia.
Stage 4 — Full-Thickness Tissue Loss
Exposed bone, tendon, or muscle in the wound bed. Slough or black eschar may cover parts. High risk of bone infection (osteomyelitis). Often requires surgery or long-term specialist care.
Unstageable — Obscured
True depth hidden by thick yellow/brown/black slough or hard dead tissue (eschar). Cannot be staged until this is gently removed by a specialist. Do not assume it is “only superficial” — it could be Stage 3 or 4 underneath.
Deep Tissue Pressure Injury (DTPI)
Intact skin with deep red, purple, or maroon discolouration — feels firm, boggy, painful, or warmer than surrounding skin. Damage is deep at muscle/bone interface. Can rapidly open into full-thickness ulcer despite looking small on the surface.
3. Risk Assessment — Waterlow & Braden
Scoring tools do not prevent ulcers — your actions based on them do. They flag who is most at-risk so preventative care can start immediately:
- Waterlow Score (most common in UK): Considers weight, skin condition, mobility, continence, nutrition, age, and additional risks.
- 10+ = At risk — implement basic prevention
- 15+ = High risk — pressure-relieving mattress + plan
- 20+ = Very high risk — specialist equipment + daily review
- Braden Scale: Six areas — sensory perception, moisture, activity, mobility, nutrition, friction & shear. Lower score = higher risk.
⚠️ Trust Your Eyes — Scores Are a Guide Only
A score is not a safety guarantee. A patient who is immobile, dehydrated, septic, or on high-dose steroids is at extreme risk regardless of the number. If you see redness or changes — act now. Document. Refer. Never wait for a score to tell you what you can already see.
4. Prevention — The Daily Care Bundle
These are the actions that actually stop ulcers forming. Consistency matters more than anything else:
- Repositioning: Bedbound patients at least every 2 hours; chairbound every 1 hour. Use a 30° tilted side-lying position — never flat on the hip at 90°, which presses directly on bony points. Document every turn.
- Heel Protection: Fully float heels off the bed surface using specialist boots or foam supports. Heels have very little padding and are the second most common site of breakdown.
- Support Surfaces: Pressure-relieving mattresses or overlays for all at-risk patients. Check the pump is working — a flat mattress provides zero protection.
- Moisture Control: Incontinence softens skin and speeds damage. Clean promptly with pH-balanced products, apply barrier cream, and change wet clothing/linens immediately.
- Nutrition & Hydration: Protein, calories, and fluids keep skin resilient. Flag poor intake to the dietitian — healing needs fuel.
- Equipment Checks: Oxygen tubing, masks, catheters, and dressings can cause their own pressure injuries. Reposition and check underneath every 4–8 hours.
5. Dressing Guide — Protection & Healing
Dressings protect — they do not cure. Choose based on skin status and keep it simple:
| Skin Status | Recommended Dressing | Why |
|---|---|---|
| Healthy Skin at Risk | Soft silicone border foam (e.g., Mepilex Border) | Reduces friction, redistributes pressure, stays in place without damaging skin on removal. |
| Stage 1 — Redness | Thin silicone or transparent film | Protects while letting you still see the skin underneath. Reassess daily — if no improvement, escalate. |
| Stage 2 — Shallow | Foam, hydrocolloid, or silicone dressing | Maintains moist healing environment, cushions, and absorbs light fluid. |
| Stage 3 & 4 — Deep | Foam, alginate, or hydrofibre — refer to Tissue Viability Nurse | Manages heavier fluid, fills dead space. Complex wounds need specialist input — do not manage alone. |
6. Reporting, Governance & Escalation
When a pressure ulcer develops during hospital care, it is not just a clinical issue — it is a governance one. Honest, prompt reporting protects patients, identifies training needs, and prevents recurrence.
🚨 New Ulcer — What You Must Do
- Document skin status clearly — describe what you see now and what was noted on admission.
- Complete trust incident report (e.g., Datix) — Category 2 and above is usually mandatory.
- Inform nurse in charge and refer to Tissue Viability Nurse (TVN) specialist team promptly.
- Update care plan — mattress, turning chart, barrier cream, nutrition referral.
- Explain honestly to the patient/family — what has happened, what is being done, and how long recovery may take.
Written by: Daniel Hancock, Registered Nurse
Clinical focus: Skin integrity, pressure ulcer prevention, ward governance
Published: September 2026 | Last reviewed: September 2026
For: UK student nurses — supervised learning only
⚠️ Always cross-reference with NICE CG179, your trust tissue viability policy, and the Tissue Viability Nurse team. This guide supports learning — it does not replace individual clinical assessment or specialist referral. When unsure — ask.