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Heal Better Together�Education Series #1��Pressure Injury Prevention​

November 17-28, 2025

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Pressure Injury and Stages�In Darkly Pigmented Skin

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Pressure Injury and Stages�In Darkly Pigmented Skin

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Pressure Injury and Stages�In Lightly Pigmented Skin

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Pressure Injury and Stages�In Lightly Pigmented Skin

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Pressure Injury Prevention

  • Assess patients for risk factors such as immobility, incontinence, malnutrition, and poor circulation. ​
  • Reassess patients' Braden Scale Q shift​.
  • Modify the environment by providing the appropriate bed (Envella or Envision per Specialty Surface Algorithm). ​
  • Ensure adequate nutrition and hydration by monitoring input and output and consulting with Dietary as needed.​
  • Reposition patients at least every 2 hours by using pillows and wedges. Encourage ambulation and self-repositioning.​
  • Keep skin dry and clean by bathing and diapering regularly.​
  • Apply moisturizers and topical creams to areas prone for breakdown.​
  • Utilize protective dressings on bony prominences and under medical devices.​
  • Educate patients about their risk of developing pressure injuries.​
  • Consult Wound Care and your Skin Champion for complex wounds, non-healing wounds, and additional information.​

Reference: https://npiap.com/page/PreventionPoints#:~:text=Inspect%20the%20skin%20at%20least,Assess%20weight%20changes%20over%20time

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Mucous Membrane Pressure Injuries​

Common Locations​

Nose (nasal cannula, nasopharyngeal airway, nasogastric tube)​, Throat (tracheostomy/endotracheal tube),​ Mouth (oropharyngeal airway, orogastric tube),​ Urethra (foley catheter),​ Rectum (fecal management system)​

Risk Factors​

Vasoconstrictor use, Diabetes Mellitus type 2, cognitive disorders, hypoproteinemia, fever

Management​

  • Examine the mucosa under and adjacent to medical devices twice per shift​.
  • Ensure that medical-related devices are the correct size.​
  • Reposition medical devices as needed​.
  • Consult primary team if suspected MMPI/poorly fitting device​.

Considerations​

Mucosal pressure injuries CANNOT be staged​

 

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Reference:

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Best practice for prevention of �medical device-related pressure injuries

  • Choose the correct size of medical device(s)
  • Cushion and protect the skin with dressings in high-risk areas
  • Inspect the skin under and around the device
  • Rotate sites of oximetry probes
  • Rotate between O2 mask(s) and prongs
  • Reposition devices if feasible
  • Avoid placement of device(s) over sites of prior or existing pressure injury
  • Educate staff on correct use of devices
  • Be aware of edema under device(s) and potential skin breakdown

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Braden Score and Interventions (I)

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Braden Score and Interventions (II)

Risk Factor

Interventions

Sensory Perception ​

- Use appropriate pressure redistribution surfaces (Ex. specialty mattress)​

- Avoid multiple layers of bedding, padding. Keep bed linens smooth​

- Elevate heels using therapeutic devices or pillows.​

- Utilize transfer devices​

- Utilize prophylactic silicone foam dressing over bony areas​

- Assess skin/ mucosal membranes under/around medical devices 2x per shift. Reposition device if possible.​

- Consult OT/PT.​

- Consult wound specialist​

Moisture

- Cleanse and moisturize as needed​

- Cleanse skin folds & perineal​ area after incontinent episodes​

- Utilize skin protectant barrier cream/wipes​

- ConsuIt OT/PT.​

- Consult wound specialist

Activity

Mobility 

*See 'sensory perception' interventions*

Nutrition

- Encourage diet & fluid​ intake as per client​ condition/ restrictions.​

- If NPO, ensure​ adequate parenteral​ hydration /nutrition.​

- Monitor intake/output.​

- Conduct BID oral care​

- Ensure that dentures​ are in place and well-​fitting.​

- Ensure that client is​ able to swallow safely.​

- Consult dietary​

Friction and Shear

- Keep HOB 30° (unless​ contraindicated). ​

- When moving client up in bed, ensure bed is flat; that hips are 10cm above​ where the bedframe flexes;​ raise knees 10-20° before HOB is raised.​

- Consult OT/PT.

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Deep Tissue Pressure Injury

  • Intact or non-intact skin with localized area of persistent non-blanchable deep red, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister.
  • Pain and temperature change often precede skin color changes.
  • Discoloration may appear differently in darkly pigmented skin
  • This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.

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Deep Tissue Pressure Injury

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Friction

  • Superficial​
  • 2 forces rubbing together (i.e., skin and a sheet) without pressure​
  • Causes abrasion-like wounds​
  • Example: Wearing pants that are too tight

Shear

  • Deep​
  • Friction + weight​
  • Skin may get stuck to sheets during repositioning, causing bone to slide against muscle, subcutaneous tissue, and skin
  • Leads to Deep Tissue Injury and stage 3 or 4 pressure injuries​
  • Example: A patient sliding down in bed