Complex Wound and Pressure Care: Prevention Is the Whole Game

A pressure injury can start in under two hours and take six months to heal. Some never heal. People die from them.

That asymmetry — hours to cause, months or years to repair — is the single most important thing to understand about this area of support. Almost everything that matters happens in prevention, and almost all the suffering comes from prevention that didn’t happen.

The frustrating part is that prevention is not complicated. Reposition people. Use the right equipment. Look at the skin every day. Keep people hydrated and fed. Act on redness immediately. None of this requires advanced clinical skill. It requires a support team that does it consistently, every day, including on busy mornings and at 3am and when someone new is on shift.

This guide covers pressure injury prevention and recognition, what complex wound care involves, the competency requirements, and what good practice looks like. It’s for participants and families. It is not clinical guidance — wound assessment and treatment belong to qualified clinicians.

Who is at risk

Pressure injuries develop where sustained pressure restricts blood flow to tissue, usually over a bony prominence. Risk rises with:

Reduced mobility — anyone who cannot reposition themselves independently, including during sleep.

Reduced or absent sensation — the warning signal that normally makes us shift position is missing. This is why spinal cord injury carries such high risk.

Moisture — incontinence, perspiration, wound exudate. Moist skin breaks down faster and the combination of moisture and pressure is particularly damaging.

Poor nutrition and hydration — tissue repair requires protein, calories, fluid and micronutrients. Someone eating poorly heals poorly and injures more easily.

Friction and shear — being dragged rather than lifted during transfers and repositioning. Shear damages tissue below the surface before anything is visible.

Existing or previous pressure injury — previously damaged tissue is permanently more vulnerable.

Medical factors — diabetes, vascular disease, low blood pressure, oedema, fever, certain medications.

The common sites: sacrum and tailbone, heels, hips, ischial tuberosities (the sitting bones), elbows, shoulder blades, the back of the head, and anywhere equipment contacts skin — under braces, around tracheostomy ties, beneath catheter tubing, at the edges of a poorly fitted wheelchair cushion.

Recognising damage early

The staging system runs from Stage 1 through Stage 4, with two additional categories.

Stage 1 is intact skin with non-blanchable redness — press it and the redness doesn’t fade. This is the critical stage. Caught here and acted on, it usually resolves. Missed, it progresses.

Stage 2 involves partial-thickness skin loss — a shallow open wound, abrasion or blister.

Stage 3 extends through the full thickness of skin into subcutaneous tissue.

Stage 4 extends to muscle, tendon or bone. These are catastrophic, frequently requiring surgery, and sometimes fatal through infection.

Unstageable means the wound base is obscured by dead tissue and the depth cannot be determined.

Deep tissue injury appears as a purple or maroon area of intact skin, or a blood-filled blister. Damage has occurred beneath the surface and may progress rapidly despite the skin appearing largely intact. This one is frequently missed because it doesn’t look like an open wound.

The practical rule for support workers: any non-blanchable redness, any discolouration, any area that feels boggy, firm, warmer or cooler than surrounding tissue, is reported the same day. Not tomorrow. Not at the next handover if someone remembers. Stage 1 caught today is an inconvenience; the same area in a week is a wound.

On darker skin tones, redness may not be visible. Look instead for colour changes relative to surrounding skin, and rely more on temperature, texture and the person’s report of discomfort. Pressure injuries are under-detected on darker skin precisely because staff are trained to look for redness.

Prevention in practice

Repositioning. The frequency should be specified by the clinical team based on individual risk — commonly every few hours, more often for higher risk. What matters is that it’s specified, scheduled, documented and actually done, including overnight, which is where it most often lapses.

Technique matters as much as frequency. Slide sheets rather than dragging. Lifting rather than pulling. The 30-degree tilt position is widely used because it keeps pressure off the sacrum and the bony prominence of the hip.

Equipment. Pressure-redistributing mattresses and cushions, specified by an OT for this person’s risk level, weight and posture. Two things routinely go wrong: equipment is specified once and never reviewed, and cushions quietly compress over time until they’re no longer doing anything while looking unchanged. A cushion more than a couple of years old warrants review.

Seating. For wheelchair users, seating is the primary pressure management system. Poor seating causes pressure injuries. Our cerebral palsy daily living guide covers seating in more detail.

Pressure relief during the day. For people who sit for extended periods, scheduled weight shifts — tilting, leaning, lifting — at intervals specified by the OT or physiotherapist.

Skin inspection. Daily, during personal care, over all at-risk areas. This is not an optional extra; it’s the detection mechanism the whole system depends on.

Moisture management. Prompt continence care, barrier creams where prescribed, breathable bedding, and addressing the cause of moisture rather than only its effects.

Nutrition and hydration. Frequently overlooked. Someone with poor intake will not heal and will injure more easily. Where intake is a concern, a dietitian referral is warranted — particularly where dysphagia is also present.

Check under everything. Equipment-related pressure injuries are common and entirely preventable: braces, splints, tubing, ties, catheter straps, oxygen tubing behind the ears.

Complex wound care

Complex wound care support was upgraded in the 2023 revision from general advice to a full High Intensity Support Skills Descriptor — a change that reflects how seriously the Commission treats it.

It covers wounds requiring more than basic first aid: pressure injuries, surgical wounds, chronic ulcers (venous, arterial, diabetic foot), skin tears in fragile skin, and wounds associated with stomas or devices.

What support typically involves, always under a wound management plan written by an appropriate clinician:

• Dressing changes at the prescribed interval, using the prescribed products and technique
• Cleaning or irrigation as specified
• Observing and documenting the wound — size, appearance, exudate volume and type, odour, surrounding skin, pain
• Managing the pressure that caused it, which is the part most often neglected while the dressing gets all the attention
• Escalating when the wound deteriorates

Wound assessment is a clinical task. Support workers observe and document; they do not assess, diagnose or decide on treatment. The distinction matters and good plans make it explicit.

Signs requiring escalation: increasing size or depth, increasing pain, new or worsening odour, increased or changed exudate, surrounding redness or heat spreading outward, fever, or the person becoming unwell. Infection in a pressure injury can progress to the bone and to sepsis.

Pain, and why it gets missed

Wounds hurt. Pressure injuries hurt, dressing changes hurt, and the pain is frequently under-recognised and under-treated — particularly for people who cannot easily report it.

Several things make this worse in disability support. Pain in someone with limited or no speech may present as agitation, withdrawal, resistance to care, changed sleep or appetite, or behaviour that gets labelled as something else entirely. Someone with reduced sensation may still have pain, and the assumption that they don’t is common and wrong. And a person who has experienced many painful dressing changes may become distressed before the dressing is even opened.

What good practice looks like: analgesia timed so it is working before the dressing change rather than given afterwards; dressing products chosen partly for how they come off; a slower pace with the person controlling when to pause; and pain recorded as an observation in its own right, at every dressing change, in a form the clinician can act on.

Healing requires a whole system

A dressing does not heal a wound. The dressing manages the wound environment while the body does the work, and the body can only do the work if everything else is in place.

The pressure must come off. A pressure injury that continues to be sat on or lain on will not heal, regardless of the dressing. This sounds obvious and is routinely the reason wounds stall for months. Offloading — through repositioning, equipment, seating changes, sometimes bed rest — is the actual treatment. The dressing is supportive.

Nutrition drives repair. Wound healing requires substantially increased protein, calories, fluid, vitamin C and zinc. Someone with poor intake will not heal. Where a wound is present and intake is marginal, a dietitian referral is not optional.

Infection must be controlled. Clinically infected wounds don’t progress until the infection is treated.

Underlying conditions matter. Diabetes, vascular disease, oedema, smoking and certain medications all impair healing and may need addressing alongside the wound itself.

Moisture balance. Too dry and tissue doesn’t regenerate; too wet and surrounding skin macerates. This is what dressing selection is actually managing, and why the clinician changes products as the wound changes.

Consistency. Dressings changed at the prescribed interval, using the prescribed technique. Changed too often, healing tissue is disrupted; left too long, exudate accumulates.

When a wound is not improving, the question is rarely “what dressing should we try next” and usually “which part of the system isn’t working”.

Where prevention most often fails

From the patterns that recur, the specific failure points:

Overnight repositioning. The most common. The daytime schedule is kept; the 2am turn quietly doesn’t happen, or happens inconsistently, and the documentation says otherwise. If a repositioning schedule exists, the overnight component is the part to verify.

Handover gaps. A skin change noticed on an afternoon shift that doesn’t reach the morning team. Pressure areas need to be communicated explicitly, not left in a note nobody reads.

Equipment that stopped working. Cushions compress, mattress pumps fail, settings get changed and not changed back. An air mattress on the wrong setting for someone’s weight provides no protection and looks identical to one on the right setting.

Short-term lapses with long consequences. A few hours in an unsuitable chair at a hospital appointment. A long car journey without pressure relief. A night in respite accommodation without the usual mattress. Damage can begin in hours.

New or agency staff. Someone who doesn’t know the repositioning schedule, doesn’t know what this person’s skin normally looks like, and doesn’t know to check under the brace.

After a wound heals. Prevention relaxes precisely when the tissue is most vulnerable. Previously damaged skin stays at elevated risk permanently.

Equipment-related injuries. Under braces, splints, tubing, ties and straps. These sites aren’t part of a standard skin check unless someone makes them part of it.

Equipment: what it does and when it stops working

Pressure-redistributing equipment is the backbone of prevention, and it is also the part of the system that silently degrades.

Mattresses. These range from high-specification foam through alternating-pressure air mattresses to low-air-loss systems. Which is appropriate depends on assessed risk, weight, posture, moisture and whether a wound already exists. An OT or clinical specialist makes that call.

What goes wrong: pumps fail or get switched off; settings get adjusted for one person and never changed back; foam compresses over years until it provides no redistribution at all while looking identical; a mattress specified for a 70kg person continues in use after significant weight change; a protective mattress is covered with layers of incontinence sheeting and towels that defeat its function entirely.

Cushions. For wheelchair users this is the single most important piece of equipment in the system. Air cushions need checking for correct inflation — regularly, not occasionally, because an under-inflated air cushion offers less protection than a basic foam one. Foam and gel cushions compress over time. A cushion more than two or three years old deserves review regardless of appearance.

Heel protection. Heels are the second most common pressure injury site and the most commonly under-protected. Floating the heels off the surface entirely, using pillows or purpose-made devices, is more effective than any mattress alone.

Positioning aids — wedges, pillows, slide sheets. Slide sheets are a prevention tool, not just a manual handling one: dragging someone across a bed causes shear injury below the surface.

Review triggers. Equipment should be reassessed after weight change, posture change, a change in mobility or continence, a new wound, a hospital admission, or simply after a couple of years. In practice, equipment is specified once at the start of a package and reviewed when something has already gone wrong.

A useful question for any provider: when was this person’s pressure care equipment last formally reviewed, and by whom? If the answer is that it came with the house, or nobody knows, that is the finding.

Funding and the practical side

Complex wound care is a high intensity support and is funded accordingly — at a higher rate than standard personal care, reflecting the training, competency assessment and clinical oversight required.

Clinical oversight needs its own funding line. Wound care nurse review, plan development, competency assessment of workers. A plan that funds the dressing changes but not the clinician who directs them leaves a provider delivering clinical care without clinical governance.

Equipment sits in assistive technology. Pressure-redistributing mattresses and cushions are typically funded as AT, usually requiring an OT assessment and quote. This takes time — build the lead time into planning rather than discovering it when a wound appears.

Consumables are a known grey area. Some wound dressings and continence products fall to the health system, some to the NDIS, and the boundary is governed by the Applied Principles and Tables of Support. Where a wound arises from a health event, dressings may sit with health services; where it relates to disability-related needs, it may sit with the NDIS. Getting this clarified early avoids a supply gap mid-treatment.

Time per task is frequently underestimated. A complex dressing change can take well over an hour, particularly where repositioning, pain management and two workers are involved. Plans costed at thirty minutes produce rushed care.

What to bring to a planning meeting: a letter from the wound care clinician specifying the support required, realistic time per episode, frequency, equipment recommendations and oversight requirements.

Who can deliver it

Complex wound care is one of the eight High Intensity Support Skills Descriptors under Module 1 of the NDIS Practice Standards. Trained support workers assessed as competent can deliver it under a plan written by an appropriate clinician — commonly a wound care nurse specialist or the treating team — with clinical oversight.

As always, training is not competency. Competency means someone qualified has observed the worker perform this person’s wound care, following this plan.

The NDIS Commission recommends annual competency assessment, reassessment when needs change, and reassessment after three or more months without delivering the support.

Many wounds warrant direct nursing involvement, at least for assessment and review, with workers performing scheduled dressing changes between visits. What matters is that the model is documented rather than assumed, and that someone clinically qualified is actually reviewing the wound regularly.

Questions for providers:

• Is there a current wound management plan, and who wrote it?
• Who provides clinical wound review, and how often?
• How many workers are competent for this person’s wound care? Who assessed them?
• Is there a repositioning schedule, and how is it documented — including overnight?
• When was the pressure-redistributing equipment last reviewed?
• How are skin checks recorded?
• What is the escalation pathway if a wound deteriorates on a weekend?
• How do you manage consumables and dressing supply?

Documentation, and why it matters more here

Wound documentation is one of the few areas where support records function as genuine clinical instruments.

A wound photographed and measured weekly, with consistent description, allows a clinician to see at a glance whether it’s improving, static or deteriorating. Deterioration over three weeks is obvious in a chart and invisible day to day.

Good practice: consistent measurement, consistent descriptive language, photographs with a measurement scale where consent is given, recording every dressing change, and recording repositioning as it happens rather than at the end of a shift from memory.

Poor practice — “dressing changed, wound unchanged” repeated daily for two months — tells a clinician nothing and allows a deteriorating wound to go unrecognised.

For the person

A few things worth knowing if this is your situation.

Report discomfort early, even if nothing is visible. Deep tissue injury starts below the surface. If something feels wrong where you sit or lie, say so.

Ask for a seating and mattress review if your equipment is more than a couple of years old, or if your weight, posture or mobility has changed.

Ask for a dietitian if your intake isn’t good. Nutrition affects healing more than most people realise.

Push for specialist review if a wound isn’t improving. Chronic wounds often need specialist wound services rather than continued management of the same dressing regimen.

Know your repositioning schedule and feel entitled to ask for it to be kept. If it’s being missed overnight, that’s worth raising formally — it’s the single most common failure point.

One pressure injury makes the next more likely. Previously damaged tissue stays vulnerable. After healing, prevention needs to be more rigorous rather than relaxed.

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We deliver complex wound and pressure care across NSW as part of our high intensity supports, in supported independent living homes, SDA dwellings, respite and people’s own homes. Our related guides cover high intensity daily personal activities and complex bowel care. Call 1300 271 824.

General information only. This guide explains what complex wound and pressure care support involves and how it is governed under the NDIS. It is not clinical guidance. Wound assessment, staging and treatment decisions must be made by qualified clinicians, and support must follow the wound management plan written by the treating team. If a wound is deteriorating or the person is unwell, seek clinical review promptly. In an emergency, call 000. The High Intensity Support Skills Descriptors are published by the NDIS Quality and Safeguards Commission and revised periodically; confirm current requirements at ndiscommission.gov.au.