Pressure ulcer dressing selection by stage 1-4

Pressure injury staging, the NPUAP system

The National Pressure Ulcer Advisory Panel (NPUAP, now NPIAP) staging system, updated in 2016 and used by every wound clinician in the US:

Always note the location (sacrum, heel, ischial tuberosity, trochanter, occiput, etc.) because location affects dressing choice and offloading strategy.

Stage 1, dressing approach

Skin is intact. The "wound" is internal, you're catching it early.

Dressing choice: often nothing, just remove the pressure. If you want a protective barrier, a thin hydrocolloid or a transparent film dressing reduces friction and shear and creates a moist environment that helps reverse the early damage. The cut-to-size hydrocolloid roll works well here.

Critical action: immediate offloading. If sacral, reposition the patient off their back. If heel, float the heel off the bed surface (heel offloading boots, pillows, or specialty cushion).

Realistic outcome: reversed in days to 1–2 weeks with consistent offloading.

Stage 2, dressing approach

Skin is broken but shallow. Looks like a blister, abrasion, or shallow open ulcer.

Dressing options (pick by exudate level):

• Low exudate: hydrocolloid sheet or cut-to-size roll. Provides moist environment + barrier. Change every 3–5 days.
• Moderate exudate: hydrocolloid (thicker) or thin foam dressing. Change every 1–3 days.
• Stalled or slow-healing stage 2: collagen sheet under a non-adherent secondary cover. The MMP binding action of collagen can restart healing. Change every 1–3 days.

Realistic outcome: 1–6 weeks to heal with consistent offloading.

Stage 3, dressing approach

Full-thickness loss exposing fat. Substantial wound. This is wound clinician territory, establish care before treating at home.

Dressing options:

• Collagen, sheet for flat wounds, powder for irregular/tunneling. The high MMP load in chronic pressure injuries is exactly what collagen addresses. Ovena collagen dressing →
• Foam secondary for moderate-to-heavy exudate management over the collagen primary.
• For tunneling or undermining wounds, the wound must be loosely packed with collagen powder or alginate ribbon to allow drainage and prevent abscess. Don't pack tightly, that causes ischemia.
• For wounds with slough or eschar, mechanical or autolytic debridement first, then collagen.

Realistic outcome: months. Often requires wound center care, specialty mattress, nutritional optimization. Some stage 3s require surgical reconstruction (flap closure).

Stage 4, dressing approach

Exposed bone, tendon, or muscle. Always wound center care. Often surgical evaluation.

Dressing strategy is similar to stage 3 but with additional considerations:

• Frequent reassessment for osteomyelitis (infection in the underlying bone)
• Negative pressure wound therapy (wound vac) is commonly added for stage 3–4 wounds
• Surgical debridement and flap reconstruction are common endpoints, especially for sacral stage 4 in non-ambulatory patients
• Aggressive nutritional support and infection management are core, not optional

Home dressing care between visits typically: collagen primary + foam secondary + meticulous documentation (photos) at every change.

Offloading, at least as important as the dressing

This is the single most important fact in pressure injury care: the perfect dressing on an unoffloaded wound will not heal. Pressure is what caused the injury. If pressure continues, the wound continues.

By location:

• Sacrum: turn off back every 2 hours minimum (bed-bound). Specialty mattress (low-air-loss or alternating pressure) if at any prolonged risk. For ambulatory patients, gel cushion in chair, no sitting on a hard chair without one.
• Heels: float heels off the bed surface entirely. Heel offloading boots are standard. Pillows under calves (not under heels) work in a pinch.
• Ischial tuberosities (sit-bone): specialty wheelchair cushion. Reposition weight every 15–30 minutes in chair-bound patients.
• Trochanter (hip): avoid lying on the affected side. 30° lateral position with pillows.
• Occiput (back of head): head positioning with foam cradle. Common in long ICU stays.

Repositioning + specialty surface + nutrition is the foundation. The dressing is the topping.

Prevention, the highest-ROI thing you can do

Most pressure injuries are preventable. The Braden Scale assesses risk based on sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Patients scoring at or below 18 are at risk and should have a formal pressure injury prevention plan.

Core prevention bundle:

1. Reposition every 2 hours minimum for bed-bound patients. Every 15–30 minutes for chair-bound.
2. Specialty surfaces (low-air-loss mattress, gel overlay) for high-risk patients.
3. Skin inspection at every shift, caregivers should look at sacrum, heels, hips, elbows.
4. Keep skin clean and dry. Incontinence-associated dermatitis weakens skin and predisposes to pressure injury.
5. Adequate nutrition and hydration. Protein and calories matter.
6. Friction and shear reduction, lift, don't drag, when repositioning. Slide sheets help.
7. Heel offloading on any patient with reduced lower-extremity mobility.

Frequently asked questions