Pressure Injuries: Staging, Prevention, and

Pressure injuries are a high-yield nursing topic because they are largely preventable, and exams emphasize correct staging, risk assessment, and stage-appropriate wound care. This guide reviews the Braden Scale, staging system, prevention priorities, treatment by stage, and common exam traps.

What Are Pressure Injuries?

Pressure injuries are localized skin and tissue damage caused by prolonged pressure, friction, or shear over bony prominences.
Most common sites: sacrum (most common), heels, and hips.
They are largely preventable with regular repositioning and skin assessment.

Braden Scale Risk Assessment

The Braden Scale assesses six risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Lower scores indicate higher risk.

Score	Risk Level
19–23	Low risk
15–18	Mild risk
13–14	Moderate risk
10–12	High risk
≤ 9	Very high risk

Pressure Injury Staging

Stage	Description	Essential Feature
Stage 1	Intact skin with non-blanchable erythema	Redness that does not turn white when pressed
Stage 2	Partial-thickness skin loss with exposed dermis	Shallow, pink or red wound bed; no fat visible
Stage 3	Full-thickness skin loss with fat visible	Subcutaneous fat visible; no muscle or bone exposed
Stage 4	Full-thickness tissue loss with muscle or bone exposed	Visible muscle, tendon, or bone
Unstageable	Covered with slough or eschar	Cannot stage until debridement is complete
Deep Tissue Injury (DTI)	Deep red, purple, or maroon discoloration	Intact or non-intact skin; may worsen rapidly

Staging Comparison at a Glance

Stage	Skin Integrity	Tissue Visible	Slough/Eschar
Stage 1	Intact	None	No
Stage 2	Partial loss	Dermis (pink/red)	No
Stage 3	Full loss	Subcutaneous fat	Possible
Stage 4	Full loss	Muscle, tendon, bone	Possible
Unstageable	Full loss	Cannot determine	Yes
DTI	Intact or non-intact	Deep red/purple/maroon	No

Prevention (Priority Actions)

Reposition every 2 hours (or every 15–30 minutes if sitting in a chair).
Keep skin clean and dry, especially after incontinence; apply moisture barrier creams.
Use pressure-redistributing surfaces (specialized mattresses, cushions).
Use lifting devices (draw sheets, mechanical lifts) to reduce friction and shear.
Keep the head of bed ≤ 30 degrees to reduce shear.
Maintain adequate nutrition with emphasis on protein, vitamins A and C, and zinc.
Inspect skin daily over bony prominences.
Do NOT massage over bony prominences or use donut-shaped cushions — both reduce blood flow.

Wound Care Management by Stage

The goal of wound care is to create an optimal healing environment by keeping the wound clean, moist, and free from infection while protecting surrounding skin. This promotes granulation tissue formation, epithelialization, and ultimately wound closure.

Stage	Treatment	Exam Points
Stage 1	Pressure relief, repositioning, protective dressing (film or foam)	No open wound; prevention is key
Stage 2	Clean with normal saline; apply transparent film, hydrocolloid, or foam dressing	Never use antiseptics (betadine, hydrogen peroxide)
Stage 3	Clean with normal saline; fill dead space with hydrogel or alginate; cover with foam dressing	May require debridement of slough
Stage 4	Same as Stage 3; may require surgical debridement or flap closure	Monitor for osteomyelitis and sepsis
Unstageable	Debride slough or eschar to determine true stage	Cannot stage until debridement is complete
DTI	Protect intact skin; monitor closely for deterioration	May evolve rapidly to full-thickness injury

Complications

Stage 4 injuries can lead to osteomyelitis (bone infection) or sepsis.
Chronic non-healing wounds may require surgical flap closure.
Pain requires appropriate analgesic management.

Nursing Assessment

Assess skin daily over bony prominences using the Braden Scale.
Identify non-blanchable erythema (Stage 1).
Measure wound size and depth.
Monitor for signs of infection: redness, warmth, purulent drainage, fever.

Nursing Interventions

Reposition every 2 hours; use pressure-redistributing surfaces.
Keep head of bed ≤ 30 degrees; use lifting devices to reduce friction and shear.
Clean and dry skin after incontinence; apply moisture barrier creams.
Provide high-protein nutrition with vitamins A, C, and zinc.
Document wound healing progress.

Patient Teaching

Change position every 2 hours if bedridden, every 15–30 minutes if sitting.
Keep skin clean and dry; eat a high-protein diet; drink plenty of fluids.
Use pressure-redistributing cushions (not donut cushions).
Inspect skin daily over bony prominences and report redness, blistering, or breakdown immediately.

Common Exam Traps

Stage 1 does NOT blanch when pressed.
Do not massage over bony prominences or use donut-shaped cushions.
Unstageable wounds require debridement before staging.
DTI presents as deep red, purple, or maroon discoloration.
The sacrum is the most common location for pressure injuries.
Clean wounds with normal saline only — not betadine or hydrogen peroxide.
Repositioning every 2 hours is the single most important preventive intervention.

Key takeaways

Pressure injuries are caused by prolonged pressure, friction, or shear over bony prominences, most commonly the sacrum.
The Braden Scale stratifies risk from low (19–23) to very high (≤ 9) using six factors.
Stage 1 = non-blanchable erythema; Stage 2 = partial-thickness; Stage 3 = fat visible; Stage 4 = muscle/bone visible; unstageable = covered by slough/eschar; DTI = deep red/purple/maroon discoloration.
Prevention priorities: reposition every 2 hours, keep skin clean and dry, maintain high-protein nutrition, and use pressure-redistributing surfaces.
Clean wounds with normal saline only; avoid antiseptics, massage over bony areas, and donut cushions.

Pressure Injuries: Staging, Prevention, and Nursing Care