Pressure Injury Prevention

What Are Pressure Injuries?

Pressure injuries (formerly called pressure ulcers or bedsores) are localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical device. They result from intense or prolonged pressure, or pressure in combination with shear forces. The most common sites include the sacrum, heels, ischial tuberosities, and greater trochanters.

Staging Classification

Stage 1: Non-blanchable erythema of intact skin. The area may be painful, firm, soft, warmer or cooler compared to adjacent tissue.

Stage 2: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, and moist. May present as an intact or ruptured serum-filled blister.

Stage 3: Full-thickness skin loss. Fat is visible and granulation tissue and rolled wound edges are often present. Slough or eschar may be visible. The depth of tissue damage varies by anatomical location.

Stage 4: Full-thickness skin and tissue loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone. Slough or eschar may be visible. Undermining and tunneling often occur.

Unstageable and Deep Tissue Injuries

Unstageable: Full-thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed.

Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon, or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister.

Braden Scale

The Braden Scale is the most widely used risk assessment tool, evaluating six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Scores range from 6-23, with lower scores indicating higher risk. A score of 18 or below generally indicates at-risk status, while scores of 12 or below indicate high risk requiring aggressive prevention measures.

Norton Scale

One of the original pressure injury risk tools, the Norton Scale assesses five factors: physical condition, mental condition, activity, mobility, and incontinence. Scores range from 5-20, with lower scores indicating higher risk. A score of 14 or below is considered the threshold for increased risk.

When to Assess

Perform risk assessment on admission to any healthcare facility, at regular intervals during the stay (every 24-48 hours for acute care, weekly for long-term care), and whenever the patient's condition changes significantly. Document results consistently and communicate risk status to all care team members.

Repositioning and Mobility

Reposition patients at least every 2 hours when in bed and every 1 hour when seated. Use the 30-degree lateral tilt position to avoid direct pressure on the trochanter. Encourage ambulation and active range of motion exercises whenever possible. Use lift devices to avoid friction and shear during repositioning.

Support Surfaces

Select appropriate support surfaces based on risk level. Low-risk patients may benefit from high-density foam mattresses. Moderate-risk patients should use alternating pressure or low-air-loss mattresses. High-risk patients may require advanced surfaces such as air-fluidized beds. Always ensure heels are elevated off the bed surface using pillows or heel suspension devices.

Skin Care and Nutrition

Keep skin clean and dry while maintaining adequate hydration. Use barrier creams to protect against moisture-associated skin damage. Apply moisturizers to dry skin areas. Ensure adequate nutritional intake with emphasis on protein (1.25-1.5 g/kg/day), Vitamin C, and zinc. Consult a dietitian for patients at nutritional risk.

Education and Documentation

Educate patients, families, and all care team members about pressure injury prevention. Document all assessments, interventions, and outcomes. Conduct regular skin inspections with particular attention to bony prominences and areas under medical devices. Report any skin changes promptly to the care team.