Pressure Ulcer Stage 1

Stage 1 pressure ulcer is intact skin with a localised area of non blanching erythema, usually over a bony prominence. It is the earliest reversible stage and the signal to intervene before skin breakdown.

• Detection is harder in dark skin, in which changes in warmth, oedema, induration, hardness and pain are more reliable than redness.
• Risk factors are those of any pressure injury.

Persistent redness that does not blanch on pressure (finger press or transparent disc test), skin intact; may be painful, firm, soft, warmer or cooler than surrounding skin.

• In dark skin the area may look darker, purple or shiny, with colour change different from the surrounding skin.
• Differential diagnosis: blanching reactive hyperaemia, deep tissue injury, moisture associated skin damage, cellulitis, contact dermatitis, fungal intertrigo, bruise, vasculitis, fixed drug eruption.
• Complications: progression to stage 2 to 4 within hours to days if pressure persists, deep tissue injury, pain, infection.

Clinical, with a blanching test and skin tone appropriate assessment.

• Palpate for temperature, oedema and firmness; document site, size and time.
• Risk assessment with Braden score; nutritional and mobility assessment.
• No laboratory tests are needed except glucose or albumin in suspected poor nutrition.

Relieve pressure immediately and protect the skin.

• Supportive: remove all pressure from the area, reposition every 2 hours using a 30 degree side lying position, do not lie on the red area, heel suspension for heels, alternating pressure or high specification foam mattress, pressure relieving cushion in the chair, limit sitting time to 1 hour, lift and do not drag (avoid shear), keep skin clean, dry and moisturised, treat incontinence, avoid massage and rubbing, avoid ring cushions.
• Pharmacological: barrier cream or film applied to the surrounding skin if moisture is present; paracetamol 1 g for pain if needed; nutritional support with protein 1.25 to 1.5 g/kg/day, energy 30 to 35 kcal/kg/day, and correction of anaemia and dehydration.
• Procedures: prophylactic soft silicone multilayer foam dressing over the sacrum or heels, changed every 3 days or when soiled, with skin inspected under the dressing at every change.
• Special groups: spinal cord injury, regular weight shifts and seating review; elderly or critically ill, hourly checks at medical device sites; dark skinned patients, rely on warmth and induration; neonates, protect from device pressure.
• Red flags: purple or maroon discolouration, boggy or very firm tissue (deep tissue injury), blistering, pain increasing, fever, extension of area.
• Follow-up: reassess every shift; resolution within 24 to 72 hours of pressure relief is expected; escalate if not improving at 48 hours.