Preventing Pressure Sores at Home: The Checks, and Where Two Guidelines Disagree

Pressure damage starts where a bone presses skin against a surface for too long, and the earliest reliable sign is not how an area looks but whether redness goes pale when you press it. On how often somebody should be repositioned, two live guidelines genuinely disagree, and the honest answer for a carer is to get a written plan from a nurse who can see the person rather than take a number from a web page. That disagreement is the reason this article exists in the shape it does.

The two documents are NICE clinical guideline CG179, published 23 April 2014 and never substantively revised, with companion quality standard QS89 from 2015¹²; and the international guideline produced jointly by EPUAP, NPIAP and PPPIA, now in a fourth edition with chapters released from 2025³. They agree on almost everything except the number that carers are most often given.

A word about what I can and cannot tell you. My mother never developed a pressure sore. What she did have, in the weeks after her coronary bypass surgery in April 2022, was far more chair time than anybody had warned us about, in a high-backed chair she could not easily get out of, and nobody mentioned skin once during the discharge. I learned what a blanching test was months later, from a district nurse who mentioned it in passing while she was there for something else. So this page is written from the guidance and from that nurse, not from a wound I managed, and where a first-hand beat belongs to somebody else I have said so.

This article sits under caring for a parent at home and pairs with moving someone safely and spotting when someone is getting worse.

Who is actually at risk?

Everybody, in principle, and a specific list of people in practice. NICE opens the guideline with a sentence worth taking literally: “Be aware that all patients are potentially at risk of developing a pressure ulcer.”¹

The risk factors that should trigger a formal assessment are set out in recommendation 1.1.2, and they map closely onto the ordinary population of people being cared for at home¹:

• Significantly limited mobility, including anyone who spends most of the day in one chair.
• Significant loss of sensation, because pain is the body’s own repositioning alarm and its absence removes the warning.
• A previous or current pressure ulcer. Skin that has been damaged once is the highest risk skin there is.
• Nutritional deficiency.
• Inability to reposition themselves.
• Significant cognitive impairment, which affects both the shifting and the reporting.

Formal risk scoring exists and belongs to the professionals: CG179 says to consider using a validated scale to support clinical judgement, naming the Braden, Waterlow and Norton scales, rather than to rely on the score alone¹. The fourth edition of the international guideline has not yet published its risk assessment chapter, so the tools above remain the ones to expect somebody to use.

Two moments concentrate the risk. The first is any period of much reduced mobility: after surgery, after a fall, during an illness, or a stretch of days when somebody simply stops getting up. The second is a hospital discharge. NICE and SCIE guideline NG27 requires the discharge plan to be given to the person and to everyone involved in their ongoing care, “including families and carers”⁴. If skin is not in that conversation and the person is going home with limited mobility, put it there yourself. Coming home from hospital covers the discharge window.

Where does damage start, and what am I looking for?

Over bony points, and you are looking for four things rather than one. NICE recommendation 1.1.5 tells clinicians assessing high-risk adults to look at skin integrity at pressure areas, colour changes or discoloration, and variations in heat, firmness and moisture¹.

That list matters because most families look only for redness, and redness is the least reliable member of the group. Heat is an area warmer or cooler than the skin around it; firmness is an area harder or boggier under your fingers; moisture is skin damp from sweat, urine or a wound. Add a fifth that is not on the list but is often first: the person’s own report that a spot is sore.

The blanching test is the one to learn. Press gently on the discoloured area with a finger and lift it off. Healthy skin goes pale and then colours again. If the area does not go pale, the redness is non-blanching, and non-blanching redness means damage has already occurred. This is not something to keep an eye on until the district nurse is next passing. It is a call. NICE’s own wording is that finger palpation or diascopy should be used to determine whether erythema or discolouration is blanchable¹.

On darker skin, do not rely on colour at all. Damage may appear purplish, bluish or simply darker than the surrounding skin, and in poor light may not be visible until it is advanced. Heat, firmness, moisture and reported pain are the more dependable signs, and the check is by feel in good light rather than a glance from the doorway. Pressure damage on darker skin is under-detected, and a carer who checks by touch is compensating for a real gap.

Write down what you find with a date. “13th, palm-sized dull red patch over the left hip, blanches. 15th, same patch, no longer blanching” is a sentence that changes what happens next, in a way that “her skin looks a bit sore” does not. Keeping a care file is where that record lives, and being heard in appointments covers getting it into a short slot.

Which places should I be checking?

The places where bone is close to the surface, and which ones depend on how the person spends their day.

• Lying on their back: the base of the spine and the tailbone, the heels, the shoulder blades, the back of the head, and the elbows.
• Lying on their side: the hip, the outer thigh, the outer ankle and the inner knees where they press together, and the ear.
• Sitting: the sitting bones, the tailbone, the shoulder blades against the chair back, and the backs of the heels and calves against a footplate.
• Everywhere, all the time: anywhere a device sits against skin. Oxygen tubing behind the ears, catheter tubing, the edge of a splint or a cast, a hearing aid, spectacle arms, and a seam or a button trapped under someone who cannot shift off it.

Heels are the site families most often miss: easy to overlook under bedding, with very little tissue between bone and surface. Check daily, at a moment already built into the day, usually washing or changing, because a check that depends on remembering will not survive a bad week.

How often should someone be repositioned, and why is there no single answer?

Because two current guidelines say different things, and the difference is real rather than a matter of wording. This is the part of the subject where a carer is most likely to be given a confident number by somebody who does not know it is contested.

What NICE says. CG179 recommendation 1.1.8, for adults at risk, is to encourage them to change position frequently and at least every 6 hours, to help those who cannot reposition themselves, and to document the frequency required. Recommendation 1.1.9 applies the same structure to adults at high risk with a floor of at least every 4 hours¹. Note the phrasing: these are minimum frequencies, not recommended ones. And note what NICE does not say. NICE does not recommend two hourly repositioning for adults. Its floors are 6 hourly and 4 hourly.

What the international guideline says. The fourth edition takes a different view. Recommendation R7 is worded: “We suggest that either repositioning at two hourly or three hourly intervals could be implemented for most individuals at risk of pressure injuries, if they are also on an appropriate pressure redistribution full body support surface.” Recommendation R8 goes further and addresses the other end directly: “We suggest not routinely extending repositioning intervals to four, five or six hourly for individuals at risk of pressure injuries.”³ Read plainly, R8 advises against the practice that CG179’s floors permit.

Why they differ. CG179 was published on 23 April 2014 and has never been substantively revised; the 2018 stamp on it reflects a stakeholder-list change rather than new evidence¹. The international guideline’s fourth edition has been released chapter by chapter from 2025, with the publishers labelling it a 2026 guideline³. Twelve years separate the evidence reviews.

What honesty requires saying about the newer numbers. R7 and R8 are both conditional recommendations resting on very low certainty evidence, in the guideline’s own grading³. That is not a reason to dismiss them. It is a reason not to treat two hourly as a settled fact either. The most defensible reading is that the international guideline reflects more recent thinking and remains uncertain, and that NICE’s floors are old and were never intended as targets.

	NICE CG179 (2014, unrevised)	International guideline, fourth edition (chapters from 2025)
At risk	Reposition at least every 6 hours (1.1.8)	Two hourly or three hourly suggested for most people at risk on an appropriate support surface (R7, conditional, very low certainty)
High risk	Reposition at least every 4 hours (1.1.9)	Suggests not routinely extending intervals to four, five or six hourly (R8, conditional, very low certainty)
How the interval is set	Document the frequency required	Individualised regimen based on activity and mobility, ability to reposition independently, skin and tissue tolerance, clinical condition, comfort, sleep patterns, goals of care and the support surface (R4, R5)
What a carer does with this	Do not adopt either number off a page. Ask the district nurse or community nursing service for a written plan for this person on this mattress, and ask when it will be reviewed.

So what do you actually do? You ask, in a way that gets a written answer. “How often should she be repositioned, given the mattress she is on, and can you write that in the care plan” is the question. If the answer is a bare number with no reference to the support surface, say that you know the guidelines differ on this and ask which one the service works to. That is the most useful thing on this page, because the interval that is right on a pressure redistribution mattress is not the interval that is right on an ordinary one.

Repositioning at night is the part that collapses first, and it collapses because carers are asleep: sleeping when you are on call covers what can be sustained, and if the honest answer is that it cannot be, that is a reason to ask for help rather than to fail quietly at it. Getting help in sets out what exists.

What do both guidelines agree on?

More than the disagreement suggests, and the agreed material is where most of the practical work is.

• Repositioning is not optional and no mattress replaces it. The international guideline’s first recommendation is to reposition regardless of the support surface in use, on the basis that “no support surface can entirely replace repositioning”³.
• The support surface matters. The strongest recommendation in the fourth edition’s support surface chapter is to use a pressure redistribution foam, meaning reactive, full body support surface for people at risk. It is graded a strong recommendation on low certainty evidence³. If somebody at risk is lying on an ordinary mattress, that is a question for the nurse.
• Position, not just frequency. Where someone is turned onto their side, the international guideline points to 30 degree lateral positioning, up to 40 degrees where needed, rather than rolling somebody fully onto a hip³.
• Do not rub. NICE recommendation 1.1.10 is flat: “Do not offer skin massage or rubbing to adults to prevent a pressure ulcer.”¹ This is the most common well-meant mistake in home caring. Rubbing a reddened area works on tissue that is already injured.
• Individualise. The fourth edition asks for a regimen built around the person’s activity and mobility, their ability to reposition independently, their skin and tissue tolerance, clinical condition, comfort, sleep patterns, goals of care and the support surface in use³. A person near the end of life whose priority is comfort is not managed like somebody recovering their mobility, and palliative care at home covers what changes when the goal changes.

Does what they eat and drink really affect their skin?

Yes, and nutritional deficiency is one of NICE’s listed risk factors for pressure damage¹. Skin under load needs protein and energy to repair itself, and dehydrated skin is more fragile.

Across UK health and care settings, 45 percent of all adults screened were at risk of disease-related malnutrition, and 56 percent of those screened in their own homes, with 24 percent underweight and 26 percent showing unplanned weight loss (BAPEN, 2022 UK Survey of Malnutrition Risk and Nutritional Care)⁵. Those are proportions of adults screened in a voluntary survey rather than a population prevalence.

For targets, ESPEN’s 2022 practical guideline on clinical nutrition and hydration in geriatrics gives a guiding value for energy intake in older people of 30 kcal per kg body weight and day, individually adjusted, and protein of at least 1 g per kg body weight and day. On fluids, older women should be offered at least 1.6 L of drinks each day and older men at least 2.0 L unless a clinical condition requires otherwise, and those are drinks rather than total fluid intake, a distinction that understates the target by about a fifth if you get it wrong⁶. ESPEN also expects older people to be screened routinely with a validated tool, at least annually in general practice⁶.

The instruction is not to try harder at mealtimes but to ask for screening and a dietitian referral when weight is falling. Eating, drinking and weight loss covers the subject, including the point at which pushing food stops being useful.

What about moisture, continence and washing?

Moisture is on NICE’s list of things to assess for a reason: skin that is persistently damp breaks down faster, and it breaks down in the same places pressure damage occurs, which is why the two get confused¹.

The work is unglamorous: change promptly, dry thoroughly and gently rather than by rubbing, and treat any new or worsening incontinence as a medical change rather than a laundry problem. Continence and keeping dignity covers products, skin care and how they are obtained in different systems. Transfers matter here too, because dragging somebody across a sheet shears the skin, and the people who need help to move are the people whose skin is most vulnerable while being moved: see moving someone safely.

When does broken skin need a nurse rather than a dressing from the chemist?

Straight away, in every case below, and no page on this site will recommend a dressing or a product. Wound care at home is a nursing job, the dressing depends on the wound, and buying something over a counter delays the assessment.

Ring for a nurse for:

• Any break in the skin over a pressure area, however small.
• Any redness that does not blanch under gentle finger pressure.
• Any blister, intact or burst.
• Any black, brown or purple area, or an area that looks like a bruise over a bony point.
• Any new pain over a bony point, including in somebody who cannot tell you in words and shows it by flinching or by refusing to be moved.
• Any wound with increasing pain, spreading redness, swelling, heat, odour or discharge.

The mechanism for getting a nurse is the same everywhere: somebody with a nursing qualification assesses the skin, decides on treatment and a repositioning plan, and arranges equipment. The named routes differ:

• United Kingdom: the GP practice, or in many areas a direct referral or self-referral to the community nursing service.
• Ireland: the HSE public health nurse.
• United States: skilled nursing at home under Medicare home health, where the person must need part time or intermittent skilled services, must be homebound, must have a face to face certification, and must use a Medicare-certified agency⁷.
• Australia: an assessment through My Aged Care, the single entry point to Australian Government funded aged care⁸.
• Canada: the provincial or territorial home and continuing care programme, which differs by province.

Who does what: GP, district nurse, social worker is the cast list if you are not sure who to ring for what, and adaptations and technology at home covers mattresses, cushions and beds and what an assessment unlocks.

This is a call today, not something to check again tomorrow

Skin damage is quiet and it moves faster than most families expect. Ring the same day if the person you look after has:

• Redness over a bony point that does not go pale when you press it gently and lift your finger.
• Any break in the skin, blister, or black or purple area over a pressure point.
• New pain over a bony point, or new distress or resistance when they are moved. New or worsening pain in somebody who cannot tell you what hurts belongs in the same-day column on its own account.
• A wound that has become more painful, redder around the edges, swollen, hot, smelly or discharging.
• A sudden drop in how much they are moving, which both increases the pressure risk and is on NICE’s list of signs of the quiet form of delirium: be “particularly vigilant for changes that may indicate hypoactive delirium, which are often missed, such as withdrawal, slow responses, reduced mobility and movement, worsened concentration and reduced appetite”⁹.
• A fall, or a spell on the floor before anyone found them. Around a third of people aged 65 and over, and around a half of people aged 80 and over, fall at least once a year (NICE guideline NG249, published 29 April 2025)¹⁰, and time spent lying on a hard surface is exactly the mechanism this page is about. Falls at home covers the rest.

Who to ring: in the United Kingdom, their GP surgery, or NHS 111 out of hours. In Ireland, their GP or the out of hours GP service. In the United States, their own doctor’s office, or the nurse line their plan runs, or an urgent care centre. In Australia, their GP, or healthdirect on 1800 022 222. In Canada, their family doctor or the provincial health line, 811 in most provinces. Elsewhere in the European Union, their own clinician.

Use the emergency number immediately for changed breathing, chest pain, one-sided weakness, changed speech, a first seizure, an unrousable person, or bleeding that will not stop: 999 or 112 in the United Kingdom and Ireland, 911 in the United States and Canada, 000 in Australia, 112 across the European Union.

If you take one thing from this page, make it the finger test and the willingness to ring about a patch of skin. The guidelines can argue about the interval. Nobody argues about non-blanching redness.