Introduction
Pressure injuries (formerly called pressure ulcers or decubitus ulcers) remain a significant patient safety concern in acute care, long-term care, and home settings. They are largely preventable with systematic risk assessment and consistent, evidence-based interventions. This guide outlines a clinical framework aligned with National Pressure Injury Advisory Panel (NPIAP) guidelines.
Step 1: Risk Assessment
Conduct a formal risk assessment on admission and whenever the patient's condition changes significantly. The two most widely validated tools are:
- Braden Scale: Assesses six subscales — sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Scores range from 6–23; lower scores indicate higher risk.
- Waterlow Scale: Widely used in the UK; considers build, skin type, sex/age, malnutrition screening, continence, mobility, and special risk factors.
Document findings at regular intervals (typically every 24–48 hours in acute care, weekly in long-term care) and communicate risk status during handoffs.
Step 2: Skin Assessment
Perform a head-to-toe skin inspection on admission and at every care episode for high-risk patients. Focus on bony prominences:
- Sacrum and coccyx
- Heels (a high-frequency site often overlooked)
- Greater trochanters
- Ischial tuberosities
- Occiput, scapulae, and elbows (for bedbound patients)
- Under medical devices: oxygen tubing, nasogastric tubes, casts, cervical collars
Note on darkly pigmented skin: Stage 1 pressure injuries (non-blanchable erythema) are more difficult to detect visually. Assess for warmth, edema, firmness, or changes in tissue consistency — do not rely on redness alone.
Step 3: Pressure Redistribution
Repositioning Schedules
Manual repositioning remains a cornerstone of prevention. Evidence supports:
- Bedbound patients: Reposition at minimum every 2 hours; some evidence supports 3-hour intervals on high-specification foam surfaces
- Chair-bound patients: Reposition every 1 hour; educate patients to perform weight shifts every 15–30 minutes if able
- 30-degree lateral tilt is preferred over the full 90-degree side-lying position to reduce trochanteric pressure
- Avoid positioning directly on a pressure injury; use positioning wedges and pillows
Support Surfaces
| Surface Type | Best For | Considerations |
|---|---|---|
| Reactive foam (high-spec) | Prevention in moderate-risk patients | Cost-effective; does not require power |
| Reactive air (static overlay) | Prevention; adjunct for Stage 2–3 | Requires inflation maintenance |
| Active (alternating pressure) | High-risk and existing Stage 3–4 injuries | Requires electricity; may disrupt sleep |
| Low air loss / air fluidized | Complex wounds with heavy exudate; burn patients | Costly; specialized equipment |
Heel offloading deserves special mention: pillows or foam wedges placed under the calves to suspend the heels completely off the mattress are standard of care for patients with limited mobility.
Step 4: Moisture and Skin Care Management
Moisture from incontinence, perspiration, or wound drainage significantly increases pressure injury risk by softening and macerating the skin. Interventions include:
- Implement a structured incontinence management program (scheduled toileting, containment products)
- Apply skin barrier creams or liquid barriers to protect perianal and sacral skin
- Use pH-balanced cleansers; avoid soap and water directly on vulnerable skin
- Address wound drainage with appropriate dressings to prevent peri-wound maceration
Step 5: Nutritional Support
Malnutrition is an independent risk factor for pressure injury development and impaired healing. Collaborate with a registered dietitian to:
- Screen for malnutrition using validated tools (e.g., MNA, MUST)
- Ensure adequate protein intake (often 1.25–1.5 g/kg/day for at-risk patients)
- Address micronutrient deficiencies (zinc, vitamin C, vitamin A) if identified
- Provide oral nutritional supplements where indicated
Step 6: Education and Documentation
Pressure injury prevention is a team effort. Ensure:
- All care staff are trained on repositioning techniques, skin assessment, and device-related injury prevention
- Patients and families understand turning schedules, the importance of nutrition, and how to report skin changes
- All assessments, interventions, and wound changes are thoroughly documented in the patient record
- Pressure injuries are staged and reported per facility protocol and regulatory requirements
Summary
Consistent application of these evidence-based practices — risk stratification, frequent skin assessment, pressure redistribution, moisture management, and nutritional optimization — forms the foundation of effective pressure injury prevention. Regular team audits and outcomes monitoring help identify gaps and sustain a culture of safe skin care.