Localized damage to the skin and/or underlying tissue, as a result of pressure or pressure in combination with sheer is termed pressure injury (EPUAP, NPIAP, & PPPIA, 2019a, p. 16). Pressure injuries usually occur over a boney prominence but may also be related to a medical device or other object (EPUAP, NPIAP, & PPPIA, 2019a, p. 16; Joint Commission, 2018). Any tube, electrode, sensor or other rigid or stiff device element under pressure can create pressure damage; examples of devices associated with pressure injuries include device securements, surgical drains, chest tubes, blood pressure cuffs, objects left in the bed or chair (mobile phone, call bell, hearing aid, needle caps, toiletry items, toys), respiratory devices (oxygen tubing, nasotracheal tubes, nasogastric tubes, continuous positive airway pressure masks), cervical collars, casts, urinary catheters, restraints, graduated compression stockings (Baranoski & Ayello, 2020; EPUAP, NPIAP, & PPPIAa, 2019a).

Factors contributing to development of pressure injuries are identified in Box 8-1. Assessment of pressure injury risk informs the development and implementation of an individualized plan to reduce risk and prevent development of pressure injury (EPUAP, NPIAP, & PPPIA, 2019a). A risk assessment tool may be used as part of the assessment of risk; although no one risk assessment tool is universally recommended, these tools are part of an assessment that must be structured, comprehensive, and based on clinical judgment (Baranoski & Ayello, 2020; Black, 2018; EPUAP, NPIAP, & PPPIA, 2019a). Several different scales are available to assess risk, such as the Norton Scale, Waterlow Scale, Braden Scale, and the Braden QD scale (for use with children) (Black, 2018; Braden, 2005; McNichol et al., 2022; Mitchell, 2018; Waterlow, 1985). Patients may have additional risk factors and/or other health problems not measured by the chosen assessment scale. Therefore, good nursing judgment may reveal the need for a higher intensity of preventive intervention than what may be identified by the scale alone (Braden, 2012). Note that the development of a pressure injury may be unavoidable, even with preventative measures and provision of evidence-based care by the health care team (Alvarez et al., 2016; NPIAP, 2017).

These risk factors are incorporated into pressure injury prevention plans, which are based on knowledge and assessment data related to the patient's clinical condition, current skin condition overall pressure injury risk status and specific risk factors, and resource availability (McNichol et al., 2022; Taylor et al., 2023). Interdisciplinary collaboration and communication are also essential to pressure injury prevention in high-risk patient populations (Bergstrom et al., 2018).

The following skill identifies potential interventions related to prevention of pressure injuries. The interventions are listed sequentially for teaching purposes; after completion of appropriate assessments, the order in which the interventions are completed is not sequential and should be adjusted based on the individual patient assessment, health status and situation, as well as nursing judgment and facility policies. Not every intervention discussed will be appropriate for every patient. Additional interventions related to prevention of pressure injuries are discussed in other chapters. Refer to Chapter 5 for nursing skills related to administering medications for pain relief. Chapter 7 provides skills addressing hygiene and skin care. Interventions related to mobility and repositioning are discussed in Chapter 9.

Assessment

Review the patient's health record and care plan for information about the patient's status and contraindications to any of the potential interventions. Assess the patient's skin at least daily, paying special attention to the skin over bony prominences and the skin in contact with medical devices (Baranoski & Ayello, 2020; McNichol et al., 2022). A full pressure injury risk assessment should be conducted as soon as possible after admission to the care service (including community-based care); after admission, a full pressure injury risk assessment should be conducted as often as required based on the patient's acuity and guided by the screening outcome (EPUAP, NPIAP, & PPPIA, 2019a). A full pressure assessment should also be conducted as a result of any change in the patient's status (EPUAP, NPIAP, & PPPIA, 2019a). Assess the patient's response to a particular intervention to evaluate effectiveness, presence of adverse effects, and indication for continuation.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

• Altered skin integrity risk
• Altered skin integrity
• Knowledge deficiency

Outcome Identification and Planning

The expected outcome to achieve is that the patient does not experience pressure injury and/or alterations in skin integrity. Other outcomes that may be appropriate include the patient and/or caregivers are able to participate in prevention activities, and the patient and caregivers verbalize an understanding of the pressure injury prevention plan.

Implementation

Action	Rationale
1. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
2. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
3. Discuss pressure injury prevention with the patient and/or patient family/caregivers. Explain what pressure injury is, the causes of pressure injuries, and the importance of a pressure injury prevention plan (McNichol et al., 2022).	These measures promote a collaborative relationship in which the patient is treated with respect. Explanation encourages patient understanding and reduces apprehension. Patient and caregiver education support engagement in care and assist patients to implement behaviors to meet goals for care (Joint Commission, 2018; Mitchell, 2018).
4. Assess the patient's skin at least daily, paying special attention to the skin over bony prominences and the skin in contact and under medical devices (Camacho-Del Rio, 2018; McNichol et al., 2022; EPUAP, NPIAP, & PPPIA, 2019a). Briefly assess the patient's skin at the pressure points during repositioning of the patient (EPUAP, NPIAP, & PPPIA, 2019a). Refer to Chapter 3 for additional skin assessment information.	Skin assessment provides information related to the patient's current status and detects impending or actual alterations in skin integrity (McNichol et al., 2022). Skin assessment provides information needed to develop an appropriate care plan (Taylor et al., 2023). For patients at risk for pressure injury, the skin should be inspected as soon as possible upon admission to a health care service, as part of every pressure injury risk assessment, and additionally based on the individual's degree of pressure injury risk (EPUAP, NPIAP, & PPPIA, 2019a). Assessment of pressure points allows for identification of alterations in status and evaluation of the effectiveness of repositioning regimen; presence of persistent erythema may indicate the need to increase frequency of repositioning; pressure points onto which the patient will be repositioned should appear fully recovered from previous loading (EPUAP, NPIAP, & PPPIA, 2019a).
5. Assess the patient's risk for pressure injury upon entry to a health care setting and on a regularly scheduled basis or when there is a significant change in the patient's condition, incorporating appropriate assessment tools and scales, based on facility policy (WOCN, 2016). Refer to Box 8-1.	Risk for pressure injury development should be determined on admission, as often as required based on the patient's acuity, and as a result of any change in the patient's status (EPUAP, NPIAP, & PPPIA, 2019a). Identification of people at risk for developing pressure injury is a critical component of prevention (Baranoski & Ayello, 2020).
6. Utilize appropriate support surfaces to redistribute tissue loads, both while in bed and when seated, based on individual patient assessment and needs, facility policy, and availability (Baranoski & Ayello, 2020; Haesler, 2018). Appropriate support surfaces may include, but are not limited to, integrated bed systems, specialized and/or low-pressure mattresses and overlays, seating surfaces and cushions, heel elevation devices, and foam positioning wedges. Note: Pressure redistribution devices should serve as adjuncts and not replacements for repositioning of patients (WOCN, 2016). Do not use foam rings, foam cut-outs, or donut-type devices. The Wound, Ostomy and Continence Nurses Society (WOCN, 2016) has developed a content-validated algorithm for support surface selection. Refer to the General Considerations below.	Support surfaces help prevent pressure injury by redistributing pressure and manage tissue loads, sequentially altering the parts of the body that bear load (to reduce the duration of loading on individual anatomical sites), managing the microclimate (moisture and temperature control), and friction and shear control (Baranoski & Ayello, 2020; Kalowes, 2018). Support surfaces also provide for proper body alignment and comfort (Baranoski & Ayello, 2020). Foam rings, foam cut-outs, or donut-type devices concentrate pressure on the surrounding tissue and should be avoided (WOCN, 2016).
7. Routinely reposition the patient: determine frequency with consideration to the patient's level of activity, physical, cognitive and psychological condition; ability to independently reposition; the type of support surface in use; general health condition; patient comfort and pain (EPUAP, NPIAP, & PPPIA, 2019a; McNichol et al., 2022). 8. Implement early mobilization to increase the patient's activity and mobility as tolerated. Develop a schedule for progressive sitting and ambulation as rapidly as tolerated by the individual patient. Collaborate with the physical and occupational therapists to develop an individualized intervention plan. Refer to Chapter 9 for additional discussion related to early mobilization and ambulation of patients.	Repositioning reduces or relieves pressure and limits the amount of time tissues are exposed to pressure and contributes to the patient's functional abilities (EPUAP, NPIAP, & PPPIA, 2019a; McNichol et al., 2022; WOCN, 2016). Mobilization and ambulation relieve pressure, contributes to the patient's functional abilities, and may reduce risk for deterioration related to prolonged immobility (EPUAP, NPIAP, & PPPIA, 2019a; Taylor et al., 2023). Early mobility plays an important role in the patient's physical and psychological well-being (Arnold et al., 2018). Physical and occupational therapists are important resources for maximizing patient mobility (Baranoski & Ayello, 2020).
9. Use a 20- to 30-degree side-lying position or flat in bed (if not contraindicated) when positioning patients at risk for pressure injury in side-lying positions (EPUAP, NPIAP, & PPPIA, 2019a; WOCN, 2016).	Avoid lying positions that increase pressure, such as the 90-degree position (EPUAP, NPIAP, & PPPIA, 2019a).
10. Maintain the head-of-bed elevation at or below 30 degrees, or at the lowest degree of elevation appropriate for the patient's medical condition.	Head-of-bed elevation at or below 30 degrees prevents shear-related injury (WOCN, 2016).
11. Consider the use of a prophylactic (preventative) dressing, such as a polyurethane foam dressing, on bony prominences, such as heels, hips, and the sacrum (Kalowes, 2018). Assess skin under a prophylactic dressing at least daily; replace prophylactic dressings that are damaged, loosened, displaced, excessively moist, or if the dressing or skin under the dressing becomes soiled and according to the manufacturer's directions (EPUAP, NPIAP, & PPPIA, 2019a).	Prophylactic dressings reduce friction, pressure and shear, protect fragile skin, and influence microclimate (Cornish, 2017; Kalowes, 2018; Lovegrove et al., 2020; EPUAP, NPIAP, & PPPIA, 2019a; WOCN, 2016).
12. Consider the use of low-friction patient care textiles, such as bed linens and patient gowns. Refer to Chapter 9 for additional information related to safe patient handling and the use of patient handling and mobility devices.	Low-friction textiles reduce shear, minimize skin irritation and dry quickly (EPUAP, NPIAP, & PPPIA, 2019a; WOCN, 2016).
13. Utilize safe patient handling interventions when moving a patient. Collaborate with the physical and occupational therapists to develop an individualized intervention plan. Refer to Chapter 9 for additional information related to safe patient handling and the use of patient handling and mobility devices.	Proper lifting, positioning, and repositioning techniques are critical to prevent injury from shearing forces (McNichol et al., 2022). Physical and occupational therapists are important resources for maximizing patient mobility (Baranoski & Ayello, 2020).
14. Provide appropriate skin and personal hygiene (Kalowes, 2018; Mitchell, 2018; Yilmazer et al., 2019). Utilize interventions to protect the skin from excessive exposure to moisture from wound exudate, perspiration, mucous, saliva, fistula or stoma effluent, and urinary and fecal incontinence. Refer to Chapters 7, 12, and 13 for additional information related to these interventions.	Exposure to excessive moisture contributes to skin damage and pressure injury development due to decreased tissue tolerance and increases susceptibility to friction, pressure, and shear (Baranoski & Ayello, 2020; Gray & Guiliano, 2018; Voegili, 2019; WOCN, 2016).
15. Provide appropriate interventions to support the patient's nutritional status and ensure adequate nutritional and fluid intake (Kalowes, 2018). Interventions may include strategies to enhance oral intake, high-calorie/high-protein nutritional supplements, fortified foods, and/or enteral or parenteral nutritional support (Baranoski & Ayello, 2020; Munoz et al., 2020). Collaborate with the registered dietician and dietary staff to develop an individualized nutrition intervention plan (Kawoles, 2018; EPUAP, NPIAP, & Pan Pacific Pressure Injury Alliance, 2019a).	Adequate calories, protein, fluids, vitamins, and minerals are required for health and tissue maintenance (Kalowes, 2018; McNichol et al., 2022). Nutritional management is an important aspect of a comprehensive care plan for pressure injury prevention (Bergstrom et al., 2018; EPUAP, NPIAP, & PPPIA, 2019a; Lovegrove et al., 2020; Munoz et al., 2020; WOCN, 2016).
16. Implement interventions to prevent pressure injury related to the use of medical devices, based on the individual patient's situation.	Interventions are necessary to prevent pressure injury related to the use of medical devices (Camacho-Del Rio, 2018; Joint Commission, 2018; EPUAP, NPIAP, & PPPIA, 2019a; WOCN, 2016).
a. Ensure correctness for patient size and application of devices in use.	Correct size and accurate application minimize pressure and shear.
b. Use prophylactic dressings under the device, as appropriate to the individual patient and clinical use (EPUAP, NPIAP, & PPPIA, 2019a).	Appropriate use of prophylactic dressing manages moisture and provides cushioning to reduce pressure (EPUAP, NPIAP, & PPPIA, 2019a).
c. Inspect the skin under the devices and observe for edema under the devices more than twice daily or more often, as indicated.	Presence of edema increases risk for alterations in skin integrity (EPUAP, NPIAP, & PPPIA, 2019a).
d. Remove device as soon as medically feasible. Routinely reposition or rotate any medical device daily when possible.	Removal prevents pressure injury. Repositioning or rotating redistributes pressure and decreases shear (EPUAP, NPIAP, & PPPIA, 2019a).
e. Keep the skin clean and dry under medical devices.	Moisture underneath medical device increases risk of alterations in skin integrity (Camacho-Del Rio, 2018).
17. Provide education to the patient and caregiver(s) about the prevention plan and ways to minimize the risk of pressure injury.	These measures promote a collaborative relationship in which the patient is treated with respect. Explanation encourages patient understanding and engagement and reduces apprehension. Patient and caregiver education assist patients to implement behaviors to meet goals for care (EPUAP, NPIAP, & PPPIA, 2019a; McNichol et al., 2022; Taylor et al., 2023; WOCN, 2016).
18. Remove gloves and additional PPE, if used. Perform hand hygiene.	Removing gloves and PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the transmission of microorganisms.
19. Evaluate the patient's response to interventions. Reassess and alter care plan as indicated by facility policies and procedures, as appropriate.	Evaluation allows for individualization of care plan and promotes optimal patient comfort.

Evaluation

The expected outcomes have been met when the patient has not experienced pressure injury and/or alterations in skin integrity, the patient and/or caregivers have participated in prevention activities, and the patient and caregivers have verbalized and demonstrated an understanding of the pressure injury prevention plan and interventions.