Pressure injury risk at home: what should a nursing review change?

A pressure injury can begin when sustained pressure or pressure combined with shear damages skin and underlying tissue. At home, prevention has to fit the person's actual day: where they sit, how they get into bed, whether they can change position, and who notices a skin change between visits. A list of products or a generic turning schedule does not answer those questions for an individual.

This article concerns risk before an injury is established. Our earlier pieces explain what a wound review considers and what to revisit when a wound is not progressing. A person with a new or worsening area of skin damage needs assessment of that area as well as prevention planning. The advice here is not a way to classify a pressure injury or choose a treatment at home.

Begin with the person's routine

Risk is easier to understand when the nurse asks where pressure occurs in the course of an ordinary day. How long does the person spend in a chair, and can they shift their weight or stand when they want to? Can they turn in bed? Does a transfer require help? Has a recent illness, fall, admission or change in energy made a familiar routine harder? The answers may differ between weekdays and weekends if support arrangements change.

The Victorian Department of Health describes structured skin-risk assessment, examination of the skin and a prevention plan based on the findings.1 Its guidance was developed for older people in hospital. A home visit has a different environment and pattern of observation, so a clinician should adapt the assessment to the person and setting rather than import a ward schedule into a living room.

The person may know that a chair is uncomfortable but have stopped mentioning it because they think discomfort is inevitable. Ask what happens before the discomfort starts, what allows them to move, and whether avoiding the chair has changed meals, conversation or time outside. This account does not identify tissue damage on its own. It helps the clinician decide what needs examining and whether mobility or equipment advice is required.

Examine skin and interpret the findings

Skin assessment needs privacy, consent and a trained clinician. The review may consider areas exposed to sustained pressure, existing damage, moisture, pain, changes in skin colour or temperature, and the person's ability to report discomfort. The appearance of a pressure injury can vary with skin tone; a plan must not rely on redness alone as the only signal.3 If the person cannot see or feel an at-risk area easily, agree on who can check it, how often the individual plan calls for a check, and how a concern will be reported.

Victorian guidance places skin examination alongside risk factors such as mobility, circulation, nutrition, continence and the current skin-care routine.1 Those are assessment domains, not a diagnosis or a universal checklist for a family member. A new painful, discoloured or broken area deserves clinical review even if the person already has a cushion or mattress described as pressure relieving.

Good documentation says where a finding is, what it looked and felt like, when it was seen, what the person reported, and who was told. If a photograph is clinically appropriate, consent, secure storage and a consistent comparison method matter. A casual image sent around a family message group can create confusion and privacy problems without ensuring that a clinician has acted.

Make movement and support realistic

Movement can reduce prolonged pressure, but the right approach depends on the person's health, mobility, comfort and treatment goals. A person who can stand safely may need a different plan from someone who requires assistance with every transfer. The clinician may need input from physiotherapy, occupational therapy, a medical practitioner or a specialist wound service. A new chair or mattress is only useful if it suits the person's body and daily activities and someone checks that it is being used as intended.

The Victorian guidance discusses repositioning and support surfaces in hospital care.1 It also states that frequency depends on skin condition, mobility, general health, the surface in use and comfort. That is a reason to create an individual plan, not to prescribe a fixed home interval from an article. Unplanned advice to move or lift someone can also create a falls or manual-handling risk. The Nursing Hub and physiotherapy and rehabilitation service can help clarify which assessment belongs with which clinician.

A workable plan names who helps at the times help is actually needed. If an older adult cannot reposition at night and no one is present, the plan has a gap that a daytime nursing visit cannot solve by itself. The nurse should make that limitation visible to the person, their supporter and the responsible provider, and help seek an appropriate review. It is safer to describe a gap honestly than to record a prevention task that nobody can perform.

Connect skin care with the wider picture

Pressure risk can change when appetite, fluid intake, continence, illness or mobility changes. Victorian guidance includes nutrition and hydration review and skin care in prevention planning.1 The Aged Care Quality and Safety Commission places pressure injuries and wounds among the clinical risks that providers should identify, monitor and manage according to the service context.2 Neither source supports prescribing a supplement, fluid target or skin product without an individual assessment.

Moisture may make skin more vulnerable, but moisture-associated damage and pressure injury are different clinical questions. A nurse should assess rather than label every skin change as pressure damage. If continence is part of the concern, the article on continence changes in later life explains why assessment comes before a revised care plan. If a person is eating less or losing weight, the responsible clinician may need to consider nutrition assessment or referral.

The home environment also matters. A bed may be accessible but difficult to turn in. A chair may be comfortable at first and uncomfortable after lunch. A person may avoid using a walking aid indoors because the path is cluttered. The review should identify what is observable and what needs another professional's assessment, then record an agreed action. It should not make assumptions about family availability or the older adult's willingness to accept a suggested change.

Pay attention to the parts of the day that a scheduled visit cannot show. An older adult may move often while a nurse is present but spend a long evening in one position. A supporter may help with morning transfers yet be unavailable overnight. Ask the person to describe those periods in their own words. If the team recommends equipment or assistance, agree how its usefulness and comfort will be checked after it is introduced. A plan can fail because the equipment is impractical, because the help is absent, or because the person has a sound reason for declining it. Each calls for a different response.

Set a review point and an escalation route

A prevention plan should state what the team is trying to prevent, what the person and supporters have agreed to do, who checks the skin, and which changes require contact before the next visit. The plan needs review after a meaningful change in mobility, health, equipment or care support. It also needs review if the person finds it burdensome or it cannot be followed in the home.

The wound and skin care pathway explains how Clinics GRP assesses an accepted nursing need and coordinates follow-up. If a care provider is referring, a useful nursing referral should include the current skin concern, mobility change, existing plan and what response is being requested. This lets the receiving clinician decide what assessment is needed rather than guessing from a request for a cushion.

Seek prompt medical or nursing advice for new skin breakdown, a painful or rapidly changing area, or a person who becomes unwell. Severe symptoms or a sudden major deterioration need urgent medical assessment. Call Triple Zero (000) for a medical emergency. Clinics GRP is not an emergency or 24-hour service. A prevention plan is useful only while it still fits the person who has to live with it.