🚩 Red flags — escalate

A suspected deep-tissue injury (a maroon or purple area or a blood-filled blister) or a rapidly developing pressure injury — urgent provider notification and offloading (staging in Wounds / Pressure Injury).

Signs of a skin or soft-tissue infection — spreading erythema, warmth, swelling, or fever (possible cellulitis) — urgent provider notification.

Necrotic or ischemic skin changes (with Peripheral Vascular) — urgent evaluation.

A serious skin reaction — widespread blistering, sloughing, or a drug reaction — urgent evaluation and emergency response per severity.

Extensive new skin breakdown — provider notification and a prevention and treatment plan.

Any existing wound that is deteriorating — evaluate and escalate per the Wounds / Pressure Injury reference.