Pressure Injuries and Skin Protection

Sustained pressure over a bony area reduces blood supply and tissue begins to die within hours, not days. The sacrum, heels, hips, elbows and the back of the head are the common sites.

The first sign is redness that does not blanch when pressed. In darker skin the change is in temperature, firmness and colour difference rather than redness, and it is missed more often.

Repositioning on a schedule rather than when someone remembers. An appropriate support surface — mattress and cushion matched to risk. Skin inspection at least daily, including heels and under any device. Nutrition, particularly adequate protein, because tissue cannot repair without it.

Moisture from incontinence or sweat weakens the skin and multiplies the risk, so continence management is part of prevention rather than separate from it.

A pressure injury that reaches deep tissue can take months to heal, can require surgery, can become infected and reach bone, and in the meantime stops the rehabilitation programme entirely.

In spinal cord injury, skin problems such as pressure injuries are among the three most common reasons for readmission to hospital in the first year after injury 4. The person cannot feel the pressure that is causing it, which is precisely why the routine has to be external and scheduled.

Pressure relief technique in a wheelchair, transfer technique that does not drag skin, skin inspection using a mirror for areas that cannot be seen, and what a developing injury looks like on their own skin.

Families are trained explicitly rather than told to be careful. Education on its own is not enough: trials of educational and behavioural programmes in people with spinal cord injury have not shown fewer pressure injuries 5. Teaching is therefore tied to the daily routine — surface, positioning and skin checks — rather than relied on by itself.

A pressure injury stops a rehabilitation programme: the patient cannot sit, cannot transfer, cannot participate, and weeks of gains are lost while it heals over months.

That is why prevention sits in the therapy plan — positioning, surface, transfer technique and nutrition are all things the programme controls, and all four have to be right.

NICE advises encouraging adults at risk to change position frequently and at least every 6 hours, and those at high risk at least every 4 hours, with help and equipment if they cannot move themselves 1. Trials comparing 2-, 3- and 4-hourly schedules have not shown which interval works better: a 2026 Cochrane review rated that evidence as very uncertain 2.

So the schedule is set for the individual and adjusted to what the skin shows. NICE suggests rechecking red or discoloured areas that do not blanch when pressed at least every 2 hours until they resolve 1. For wheelchair users, it also recommends considering a high-specification foam or equivalent pressure-redistributing cushion 1.