Pressure injury nursing: staging, prevention, and wound care

A pressure injury is localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device. The damage results from intense or prolonged pressure, or pressure in combination with shear. Pressure injuries are among the most common and preventable hospital-acquired conditions in the US, affecting an estimated 2.5 million patients per year and contributing to significant morbidity, extended hospital stays, and increased mortality (AHRQ, 2014).

For nursing students, pressure injuries are high-yield content. The NCLEX expects you to know staging criteria, risk assessment tools, evidence-based prevention, and appropriate wound care by stage. This guide covers all of it, from the NPUAP/EPUAP 2016 updated classification system through clinical wound management.

Terminology: pressure injury vs. pressure ulcer

The National Pressure Injury Advisory Panel (NPIAP, formerly NPUAP) updated terminology in 2016, replacing “pressure ulcer” with “pressure injury” to better reflect the continuum of tissue damage. The term now encompasses both open and intact skin. You will encounter both terms in clinical practice and on NCLEX – they refer to the same condition, and the staging criteria are identical.

NPUAP/EPUAP 2016 staging system

The current staging system classifies pressure injuries into six categories. Staging is assigned based on the deepest visible tissue layer – but only when the wound can be visualized. Never stage a wound that is covered by eschar or slough until it is debrided.

NCLEX tip: the unstageable rule

The NCLEX frequently asks: which wound cannot be staged? The answer is always the wound covered by eschar or thick slough. You cannot assign a Stage 3 or Stage 4 to a wound you cannot see into. Eschar obscures depth. Once debrided, the wound gets its true stage.

A second frequent NCLEX theme: DTPI looks minor but indicates deep tissue destruction. A purple bruise-like area over a bony prominence in an immobilized patient is DTPI until proven otherwise – not a Stage 1.

Risk assessment: the Braden Scale

The Braden Scale is the most widely used and validated pressure injury risk assessment tool in the US. It was developed by Barbara Braden and Nancy Bergstrom in 1987 and measures six subscales that capture the primary mechanisms of pressure injury development. Each subscale is scored 1–3 or 1–4, with lower scores reflecting greater impairment. The total score ranges from 6 to 23.

Braden risk thresholds

Braden Scale is typically completed on admission, every 24 hours in acute care, after any significant change in condition, and on transfer. A score ≤18 triggers a formal prevention protocol in most facilities.

Common pressure injury sites

Pressure injuries form where soft tissue is compressed between bone and an external surface. The sacrum and coccyx account for approximately 28% of all hospital-acquired pressure injuries (Bauer et al., 2016, AHRQ). The most common sites by setting:

• Bedbound patients: sacrum/coccyx, heels, greater trochanters, ischial tuberosities, occipital scalp (especially in pediatric patients)
• Sitting/chair-bound patients: ischial tuberosities, sacrum, feet
• Medical device–related: nasal bridge (BiPAP/CPAP mask), nares/columella (NGT, nasal cannula), ears (oxygen tubing), forehead and chin (cervical collar), fingers and toes (pulse oximetry probes), wrists (restraints)

Prevention protocols

Prevention is the nurse’s first responsibility. The majority of pressure injuries are preventable with consistent application of evidence-based interventions.

Repositioning

Repositioning is the cornerstone intervention. The standard recommendation for bedbound patients is repositioning at least every 2 hours (q2h), though some patients with high Braden risk require q1h repositioning (NPIAP, 2019). Specific protocols:

• Supine patients: 30-degree lateral tilt (not full lateral decubitus, which places pressure on the greater trochanter) is preferred over full side-lying. Use positioning wedges to maintain the angle.
• Head of bed (HOB): Keep HOB at 30 degrees or lower whenever clinically safe. Elevating HOB above 30 degrees dramatically increases shear force on the sacrum as the body slides toward the foot of the bed. Elevate only for necessary clinical reasons (aspiration risk, feeding times) and return to 30 degrees promptly.
• Chair-bound patients: Reposition at least every hour. Patients with sufficient upper extremity strength can be taught to perform 15-second pressure-relief lifts every 15 minutes.
• Heels: Heels must be completely offloaded – not just padded. Use heel-offloading boots or elevating the calves on pillows to suspend heels free of the mattress. Foam heel protectors cushion but do not offload; they do not substitute for true heel suspension.

Skin care and moisture management

Moisture doubles the risk of pressure injury by softening (macerating) the stratum corneum and increasing friction. Management approach:

• Skin inspection: Inspect all bony prominences at least once per shift. In high-risk patients, inspect with each repositioning turn.
• Moisture barriers: Apply a barrier cream or film-forming product to skin exposed to incontinence, wound drainage, or excessive perspiration. Moisture barriers protect intact skin from external moisture – they are NOT the same as moisture-retentive dressings (which manage wound exudate from an open wound).
• Incontinence management: Structured toileting programs, containment devices (external catheters, fecal management systems), and prompt skin cleaning after each incontinence episode all reduce moisture exposure.
• Bathing: Use pH-balanced skin cleansers rather than soap. Soap disrupts the acid mantle of the skin and increases fragility.
• Do NOT massage: Never massage reddened bony prominences. Massage increases tissue trauma and capillary disruption over areas that are already at risk or injured. This is a common NCLEX distractor.

Nutrition

Malnutrition is an independent risk factor for both pressure injury development and impaired healing. Nutritional targets for patients at risk or with existing pressure injuries (NPIAP, 2019; ASPEN):

• Protein: 1.2–1.5 g/kg/day for at-risk patients; up to 2.0 g/kg/day for Stage 3 and Stage 4 injuries
• Calories: 30–35 kcal/kg/day
• Vitamin C: Supports collagen synthesis; supplementation often recommended in patients with deficiency or active wounds
• Zinc: Supports cell proliferation and immune function; supplement when deficiency is confirmed
• Hydration: Adequate fluid intake is required for all wound healing

Refer to a registered dietitian for any patient with an existing pressure injury Stage 2 or higher, or any patient with Braden nutrition subscale score ≤2.

Support surfaces

Support surfaces redistribute pressure across a larger body surface area, reducing the peak pressures at bony prominences. They are adjuncts – not substitutes – for repositioning.

Reactive surfaces respond passively to the patient’s weight distribution (e.g., foam overlays, static air mattresses, water overlays). Indicated for patients at moderate risk (Braden 13–18) who can be repositioned regularly.

Active surfaces use powered systems to alternate pressure cyclically or create a low-air-loss environment. Indicated for high-risk patients (Braden ≤12), patients who cannot be repositioned due to clinical instability, or patients with existing Stage 3 or Stage 4 injuries. Low-air-loss surfaces also help manage moisture and skin temperature.

Standard hospital mattresses provide almost no pressure redistribution. A patient admitted with any Braden score ≤18 should be upgraded from a standard mattress.

Wound care by stage

Stage 1

Stage 1 injuries require aggressive offloading and protection of intact skin. The goal is preventing progression, not managing an open wound.

• Offload completely: Remove the causative pressure source. No direct contact with the affected bony prominence until the Stage 1 resolves.
• Protect with barrier cream or transparent film dressing: A thin transparent film can protect against friction. Some clinicians use a thin foam dressing to further cushion the area.
• Do NOT massage: Never massage a Stage 1 injury. Massage causes further capillary damage.
• Monitor closely: A Stage 1 can progress to Stage 2 within hours in a patient with poor perfusion. Assess with every turn.

Stage 2

Stage 2 injuries involve partial-thickness skin loss. The wound bed is viable. Management focuses on maintaining a moist wound environment that supports re-epithelialization while protecting the wound from contamination and further trauma.

Dressing options for Stage 2:

• Hydrocolloid: Self-adhesive, occlusive, moist environment. Change every 3–7 days or when dressing integrity is compromised. Excellent for sacral Stage 2 wounds with low to moderate exudate.
• Foam dressing: Absorbs exudate, cushions, maintains moisture. Choose for wounds with moderate exudate or in high-friction locations. Change every 3–5 days.
• Transparent film: Semi-permeable membrane; maintains moist environment; allows visual inspection without removal. Best for shallow, low-exudate wounds and intact blisters. Not appropriate for draining wounds.
• Hydrogel: Adds moisture to the wound bed; best for dry, low-exudate wounds. Less common for Stage 2 than for Stage 1 transitions.

Do not unroof intact blisters unless the blister is tense, painful, or in a location prone to rupture. A ruptured blister should be dressed to maintain a moist environment.

For guidance on broader wound documentation practices, see the wound assessment nursing guide.

Stage 3 and Stage 4

Stage 3 and Stage 4 injuries require full wound care management. The principles are: achieve a clean wound bed (debridement), maintain moisture balance, manage bioburden, fill dead space, and support systemic healing.

Debridement

Dead tissue (necrotic slough, eschar) must be removed to allow healing. Debridement types:

• Autolytic: Uses the body’s own enzymes and moisture (occlusive dressings create the environment). Slowest method. Appropriate for wounds with good perfusion and adequate immune response. No contraindication in stable wounds.
• Enzymatic: Topical enzyme products (e.g., collagenase/Santyl) selectively digest necrotic tissue. Faster than autolytic. Requires a physician/NP order and should not be used simultaneously with silver or iodine products (they inactivate the enzyme).
• Sharp/surgical debridement: Removal by scalpel or scissors. Fastest method. Performed by a trained clinician (wound care nurse, surgeon, NP/PA). Required for infected wounds, wounds with thick eschar, or when rapid progression is needed.
• Mechanical: Wet-to-dry dressings – rarely recommended due to non-selective tissue removal and pain.
• Biological (maggot therapy): Sterile maggots selectively consume necrotic tissue. Limited use but evidence-based for complex, infected wounds unresponsive to other methods.

Deep wound management

• Fill dead space: Pack tunneled or undermined wounds loosely with appropriate material (hydrogel-impregnated gauze, alginate rope) to prevent abscess formation. “Loosely” is critical – tight packing impairs perfusion.
• Moisture balance: Stage 3 and 4 wounds frequently produce moderate to heavy exudate. Alginate or high-absorbency foam dressings absorb exudate while maintaining wound moisture. Change frequency depends on exudate level.
• Bioburden management: Topical antimicrobials (silver-containing dressings, cadexomer iodine) for wounds with signs of critical colonization or local infection. Systemic antibiotics only for surrounding cellulitis, osteomyelitis, or systemic sepsis.

Negative pressure wound therapy (NPWT)

NPWT (wound VAC) applies continuous or intermittent subatmospheric pressure to the wound bed via a sealed foam dressing and drainage tubing. Indications for Stage 3 and 4 pressure injuries:

• Large wound requiring drainage and contraction
• Wounds with tunneling or undermining (after debridement)
• Post-surgical wound closures in pressure injury patients
• As a bridge to surgical closure (skin grafting, flap repair)

Contraindications include untreated osteomyelitis, exposed blood vessels or nerves, necrotic tissue with eschar still present, and malignancy in the wound. NPWT settings and dressing change frequency follow manufacturer and institutional protocols.

Stage 4 wounds exposing bone should prompt early involvement of a wound care specialist and assessment for osteomyelitis, which can develop when bone is chronically exposed and contaminated.

Dressing selection reference

Nursing assessment and documentation

Assessment frequency

• High-risk patients (Braden ≤12): Full skin inspection with each repositioning turn, minimum every 2 hours
• Moderate-risk patients (Braden 13–18): Full skin inspection at least once per shift
• Any patient with an existing pressure injury: Assess the wound at each dressing change and at minimum once per shift

Skin inspection must include all bony prominences and all device contact points. Darkly pigmented skin requires palpation for warmth, firmness, or bogginess, since erythema may not be visible.

PUSH tool documentation

The Pressure Ulcer Scale for Healing (PUSH) tool, developed by NPIAP, provides a standardized method for tracking healing over time. Three components are scored:

1. Length × width (surface area in cm²): Score 0 (healed) to 10 (>80 cm²)
2. Tissue type: Score 0 (epithelial/closed) to 4 (necrotic tissue)
3. Exudate amount: Score 0 (none) to 3 (heavy)

Total PUSH score ranges from 0 to 17. Scores are tracked over time; a decreasing score indicates healing. The PUSH tool supplements but does not replace narrative wound documentation, which should include all standard wound assessment parameters per the wound assessment nursing guide.

Interdisciplinary team roles

Pressure injury management is fundamentally team-based:

• RN: Primary skin assessment, wound documentation, dressing changes, family education, repositioning schedule coordination
• Wound care nurse/CWOCN: Complex wound management, debridement assistance, NPWT setup and management, specialty dressing selection
• Registered dietitian: Nutritional assessment and supplementation recommendations
• Physical/occupational therapist: Mobility optimization, seating assessment, positioning equipment recommendations
• Physician/NP/PA: Orders for debridement, systemic antibiotics when indicated, surgical referral, imaging for suspected osteomyelitis
• Family/caregiver: Education on repositioning technique, skin inspection, nutritional support, signs of worsening

Family and patient education

Education should cover: the cause of pressure injuries and why they form, how to perform visual and tactile skin inspection, the repositioning schedule and technique, nutritional priorities, and clear criteria for when to call the nurse (any new discoloration, open skin, or increased pain).

Complications

Left untreated, pressure injuries progress. Stage 3 and Stage 4 wounds create conditions for serious systemic complications:

• Cellulitis: Bacterial invasion of surrounding tissue; presents with expanding erythema, warmth, induration. Requires systemic antibiotics. Monitor for progression toward sepsis.
• Osteomyelitis: Bone infection from contiguous spread from a Stage 4 wound or deep Stage 3. Suspect when bone is exposed, when healing stalls despite optimal care, or when the patient develops fever, elevated WBC, or elevated ESR/CRP without another source. Diagnosis confirmed by MRI or bone biopsy. Treatment requires weeks of IV antibiotics and often surgical debridement. See osteomyelitis nursing.
• Sepsis: Pressure injuries are a common portal of entry for gram-positive and gram-negative bacteria. Any patient with an existing wound and unexplained SIRS criteria (fever, tachycardia, elevated WBC, altered mental status) requires full sepsis nursing evaluation.
• Tunnel/sinus tract: Undermining or tunneling that is not managed can become a closed abscess. Always probe wounds carefully and document tunnel direction and depth.

Review the patient’s CBC, BMP, albumin, and prealbumin to assess nutritional status and systemic response to infection. The nursing lab values cheat sheet covers interpretation of these values in context.

NCLEX review: key themes

Pressure injuries appear frequently on NCLEX-PN and NCLEX-RN, particularly in prioritization and intervention questions. The following themes recur:

1. Priority action on finding a Stage 2 pressure injury The priority action is to notify the provider and implement a formal wound care plan. Before that: offload the area. A common NCLEX distractor asks whether you should massage the area – never massage.

2. Heel offloading: cushion vs. true offload Foam heel protectors cushion but do not offload. The NCLEX tests whether students understand that only suspending the heel free of the mattress constitutes true offloading. Answer choices with “apply heel protectors” are typically incorrect when the question asks about pressure relief.

3. Moisture barrier vs. moisture-retentive dressing A moisture barrier cream (e.g., zinc oxide, petrolatum) protects intact skin from external moisture (incontinence, sweat). A moisture-retentive dressing (hydrocolloid, foam, transparent film) manages exudate from an open wound and maintains a moist healing environment. These serve completely different purposes. NCLEX writers use them as distractors against each other.

4. Which wounds are unstageable? Any wound covered by thick slough or stable eschar cannot be staged. The correct answer is always “unstageable” until the wound bed is visible. Removing eschar to determine depth is not appropriate for stable, dry heel eschar in a patient with inadequate perfusion – this is a specific NPIAP exception.

5. Braden scale scoring direction Lower scores = higher risk. Students frequently invert this. A Braden of 9 is severe risk; a Braden of 20 is no risk. On NCLEX questions asking you to prioritize which patient needs intervention first, the patient with the lowest Braden score is your priority.

6. DTPI recognition Purple or maroon discoloration over a bony prominence is DTPI until the clinician says otherwise. Do not dismiss it as bruising or Stage 1. The hallmark of DTPI is that it often looks much less severe than the underlying tissue destruction.

7. Repositioning angle 30-degree lateral tilt is preferred over full 90-degree side-lying. Full side-lying places pressure directly on the greater trochanter, which is a bony prominence. The 30-degree tilt offloads the trochanter while still relieving sacral pressure.

Quick-reference summary

• Stage 1: Non-blanchable erythema, skin intact. Offload, barrier cream, no massage.
• Stage 2: Partial-thickness loss. Moist wound environment: hydrocolloid, foam, or transparent film.
• Stage 3: Full-thickness loss to subcutaneous fat. Debridement, fill dead space, moisture balance.
• Stage 4: Full-thickness loss with exposed bone/tendon/muscle. Aggressive debridement, consider NPWT, surgical referral likely.
• Unstageable: Cannot determine stage until wound bed visible (eschar/slough covers base).
• DTPI: Intact or non-intact purple/maroon discoloration; may evolve rapidly to deep wound.
• Braden ≤18: Formal prevention protocol. Braden ≤12: high risk – specialty surface, q1–2h repositioning, dietitian consult.
• Prevention hierarchy: Reposition q2h, HOB ≤30°, offload heels, moisture management, adequate protein.

Sources

• National Pressure Injury Advisory Panel (NPIAP). Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. 2019 Third Edition. European Pressure Ulcer Advisory Panel (EPUAP), Pan Pacific Pressure Injury Alliance (PPPIA).
• Agency for Healthcare Research and Quality (AHRQ). Preventing Pressure Ulcers in Hospitals. Updated 2014. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/index.html
• Bauer K, Rock K, Nazzal M, Jones O, Qu W. Pressure Ulcers in the United States’ Inpatient Population From 2008 to 2012: Results of a Retrospective Nationwide Study. Ostomy Wound Management. 2016;62(11):30–38.
• National Pressure Injury Advisory Panel. NPIAP Pressure Injury Stages. 2016. https://npiap.com/page/PressureInjuryStages
• Braden BJ, Bergstrom N. A conceptual schema for the study of the etiology of pressure sores. Rehabil Nurs. 1987;12(1):8–12.
• Stotts NA, Rodeheaver GT, Thomas DR, et al. An instrument to measure healing in pressure ulcers: development and validation of the pressure ulcer scale for healing (PUSH). J Gerontol A Biol Sci Med Sci. 2001;56(12):M795–M799.
• American Society for Parenteral and Enteral Nutrition (ASPEN). Clinical Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients. 2009 (with subsequent updates).