Pressure Injury Prevention Guide

Pressure injuries occur when sustained mechanical load — pressure alone, or combined with shear — exceeds the capillary pressure in tissues, causing ischemia, cell death, and tissue breakdown. They develop most commonly over bony prominences: sacrum, heels, ischial tuberosities, trochanters, and occiput.

Pressure injuries are classified as hospital-acquired pressure injuries (HAPIs) when they develop during a hospital stay. They are a CMS (Centers for Medicare and Medicaid Services) "never event" — facilities do not receive additional reimbursement for treating Stage 3, Stage 4, or unstageable HAPIs.

Prevention is the nursing priority. The two key pathophysiologic forces to address:

• Pressure: Perpendicular compressive force — prevented by repositioning and pressure-redistribution surfaces
• Shear: Parallel forces from sliding — prevented by proper positioning, HOB restrictions, and use of lift sheets
• Friction: Mechanical surface contact — prevented by protective dressings, proper transfer technique
• Moisture: Incontinence, perspiration — prevented by moisture barriers and incontinence management

The Braden Scale is the most widely used standardized pressure injury risk assessment tool. It evaluates six subscales, each scored 1–3 or 1–4:

Additional Risk Factors

• Advanced age — skin becomes thinner, less elastic, reduced subcutaneous fat
• Diabetes mellitus — peripheral neuropathy, impaired circulation, impaired wound healing
• Malnutrition and dehydration — protein deficiency impairs tissue repair
• Hemodynamic instability, shock states — reduced peripheral perfusion
• Incontinence — maceration of skin from prolonged moisture exposure
• Altered level of consciousness or sedation — inability to perceive or respond to discomfort
• Medical devices (oxygen tubing, NG tubes, casts) — device-related pressure injuries are increasingly recognized

Complete head-to-toe skin assessment upon admission and with each shift — inspect all bony prominences and any area in contact with a medical device. Skin assessment is the foundation of prevention: you cannot intervene on what you have not assessed.

• Primary assessment sites: Sacrum/coccyx (most common), heels (highest risk for ischemia), ischial tuberosities, trochanters, elbows, occiput, ears, malleoli, scapulae
• Blanchable vs. non-blanchable erythema: Press skin with finger for 3 seconds — if erythema blanches (whitens), perfusion is intact; if it does not blanch, microcirculation is compromised (Stage 1 indicator)
• Dark skin tones: Blanchability may be harder to assess — look for changes in skin color, temperature (warmth or coolness compared to surrounding tissue), texture, and bogginess or firmness
• Documentation: Describe location, size (length × width × depth), stage, wound bed characteristics, exudate, and periwound skin at each assessment
• Medical device check: Assess skin under and around all devices — oxygen tubing, nasogastric tubes, Foley catheters, endotracheal tubes, pulse oximetry probes, splints, compression stockings — at least every 2 hours

Repositioning is the most fundamental pressure injury prevention intervention — it relieves sustained pressure on at-risk tissues. Frequency is individualized based on Braden score, skin assessment, and patient tolerance.

• Standard schedule: Every 2 hours for bed-bound patients; every 1 hour for chair-bound patients; individualize based on Braden score
• Positioning — lateral: Tilt 30 degrees (not full lateral 90 degrees) to avoid direct pressure on trochanter
• Positioning — supine: HOB ≤30 degrees to minimize shear — except when clinical needs require elevation (VAP prevention, tube feeding); use foot board to prevent sliding
• Heel offloading: Heels must be completely offloaded from the mattress — use heel-elevation boots or pillow under lower leg; never use ring cushions (doughnut pillows) which concentrate pressure
• Transfer technique: Use lift sheets to transfer and reposition — never drag patients across sheets (causes friction and shear)
• Chair positioning: Patients in wheelchairs should perform pressure relief every 15–30 minutes (lift/shift) if able; consider tilt-in-space wheelchair for those who cannot

Malnutrition significantly increases pressure injury risk and impairs wound healing. Nutritional assessment and optimization are core components of pressure injury prevention and management.

• Protein: Essential for tissue repair and maintenance — adequate protein intake (1.2–1.5 g/kg/day for at-risk patients) is critical
• Hydration: Dehydration impairs skin integrity and tissue perfusion — encourage fluid intake unless contraindicated
• Calories: Caloric deficit promotes catabolism, reducing available substrates for tissue repair
• Micronutrients: Vitamin C (collagen synthesis), zinc (cell proliferation), and vitamin A support wound healing
• Nutritional screening: Use validated tool (e.g., MNA, MUST) on admission; refer to dietitian for at-risk or malnourished patients
• Supplements: Oral nutritional supplements (high-protein) may be indicated for patients who cannot meet needs through diet alone

• Complete skin assessment and Braden Scale on every admission — document findings as baseline
• Implement a repositioning schedule based on Braden score — document repositioning in the care record
• Use pressure-redistribution support surfaces (foam, alternating-air mattresses) for high-risk patients
• Keep skin clean and dry — moisture barriers and incontinence products for incontinent patients
• Apply prophylactic dressings (multilayer foam) to sacrum and heels for high-risk patients
• Offload heels completely — heels are the second most common site for pressure injuries and are especially vulnerable due to their anatomy
• Manage device-related pressure risks — reposition devices, pad skin under medical equipment
• Involve occupational and physical therapy — mobility programs and assistive devices reduce immobility risk
• Educate patients and families — teach pressure relief techniques, signs of early pressure injury, and when to call for help