Pressure Injury Prevention at Home: Repositioning, Skin Care, and Daily Skin Inspection

Who needs this teaching

Clients with limited mobility at home, including clients who are bedbound or use a wheelchair, and the caregivers who provide daily care. A pressure injury is localized damage to the skin and underlying soft tissue, usually over a bony prominence. It results from intense or prolonged pressure, or pressure combined with shear. Risk factors include immobility, sensory loss, incontinence, malnutrition, dehydration, older age, and impaired perfusion. A Braden Scale score of 18 or lower indicates risk; a lower score indicates higher risk.

The priority teaching points

1. Repositioning. Reposition the bedbound client at least every 2 hours. Reposition the client seated in a chair at least every hour. A client who is able shifts weight every 15 minutes. Lift the client with a draw sheet; dragging causes shear and friction injury.
2. Positioning. Use a 30-degree lateral tilt with a pillow behind the back, not a 90-degree side-lying position over the greater trochanter. Keep the head of the bed at 30 degrees or lower unless contraindicated; higher elevation increases shear over the sacrum. Place pillows between the knees. Do not use ring or donut cushions; they concentrate pressure on surrounding tissue.
3. Heel offloading. Float the heels with a pillow under the calves so the heels do not touch the mattress.
4. Support surfaces. Use a pressure-redistribution mattress and seat cushion as prescribed. A support surface does not replace repositioning.
5. Skin and moisture care. Cleanse the skin promptly after each episode of incontinence with a pH-balanced cleanser and warm water. Pat dry; do not rub. Apply a moisture barrier cream to the perineal skin. Moisturize dry skin daily. Change wet briefs and linens promptly.
6. Nutrition and fluids. Provide adequate calories, protein, and fluids unless restricted. Adults at risk with malnutrition need 1.25 to 1.5 g/kg of protein daily, or the amount the provider or dietitian sets. Include protein at each meal. Report weight loss and poor intake.
7. Daily skin inspection. Inspect the skin daily over the sacrum, coccyx, heels, hips, elbows, scapulae, occiput, and ears, and under medical devices such as oxygen tubing. Press reddened skin lightly. Redness that does not blanch indicates a stage 1 pressure injury. In darkly pigmented skin, assess for color change, warmth, edema, or induration. Keep the client off reddened areas. Never massage reddened skin over bony prominences; massage damages tissue already injured by pressure.

Red flags the client reports

Teach-back questions

• "Show me how you will turn your family member onto the side."
• "How often will you change position in bed and in the chair?"
• "How will you keep the heels off the mattress?"
• "What will you do if you find a red area that does not fade?"
• "Which foods will you offer for protein?"

Teaching tips

• Post a written turning schedule at the bedside.
• Observe a return demonstration of the 30-degree tilt and heel floating.
• Teach the caregiver to inspect the skin during bathing and brief changes.

Read more on NCLEXPace

• Pressure Injury Staging and the Prevention That Works
• Positioning Cheat Sheet: The Right Position for 30 Situations
• Immobility and VTE: Prevent the Clot Before It Travels

Sources

• European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Haesler E, ed. EPUAP/NPIAP/PPPIA; 2019.
• Edsberg LE, et al. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016;43(6):585-597.