Pressure injuries are among the most preventable harms in inpatient care, and nurses sit at the center of preventing them. The work starts within hours of admission and continues through every shift, handoff, and discharge teaching moment. What follows is a practical, head-to-toe view of how bedside nurses can structure prevention across the whole stay.
Start at Admission: Risk and Skin Assessment
Two assessments belong in the first hours of admission, ideally before the patient settles in for the shift.
The first is a structured risk assessment. Most facilities use the Braden Scale, which scores six domains: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. A meta-analysis of 60 studies found the Braden Scale has moderate predictive validity, with a commonly used cut-off score around 18 flagging some degree of risk. The important point for practice is that the scale is a trigger, not a diagnosis. The authors specifically recommend using it alongside clinical judgment rather than as a standalone tool. A patient can score "low risk" and still be vulnerable because of a vasopressor drip, a long OR case, or a device pressing on skin.
The second is a comprehensive skin assessment from head to heels. Inspect the bony prominences that account for most injuries: sacrum, coccyx, heels, ischial tuberosities, and greater trochanters. Look for non-blanchable erythema, localized warmth, boggy or firm tissue, and changes in sensation. On darker skin tones, color change may be subtle, so palpate for temperature and texture differences rather than relying on redness alone. Document what you find at admission so a later finding is not mistaken for a hospital-acquired injury.
Reassess both skin and risk on a schedule: each shift, after any significant change in condition, and after procedures or transfers. Risk profiles shift quickly when mobility, nutrition, or hemodynamic status changes.
Build the Prevention Bundle Into the Shift
Prevention works best as a bundle of small, reliable actions rather than a single intervention. A systematic review of multifaceted interventions concluded that combining education, care bundles, and positioning strategies is highly effective at reducing pressure injury prevalence and improving nursing practice. Translate that into bedside habits:
- Repositioning. Reposition at-risk patients on a regular schedule and use the 30-degree lateral tilt to keep weight off the sacrum and trochanter. The traditional "every two hours" interval is a reasonable default, though current best-practice reviews note the right interval depends on the support surface and the individual patient. For seated and wheelchair-dependent patients, pressure-relief maneuvers are needed far more often.
- Offload heels. Float heels off the bed with a pillow under the calves or use heel-suspension devices. Heels have little subcutaneous padding and are easy to miss.
- Manage moisture. Keep skin clean and dry, treat incontinence promptly, and apply barrier products such as zinc oxide to protect against incontinence-associated dermatitis, which weakens the skin barrier.
- Match the support surface. High-specification foam or alternating-pressure mattresses lower incidence compared with standard surfaces for higher-risk patients. Re-evaluate the surface as risk changes rather than setting it once.
- Protect against device-related injury. Check skin under and around oxygen tubing, cervical collars, SCDs, tubing, and lines. Reposition or pad devices and rotate sites per policy.
Nutrition Is a Nursing Concern Too
Adequate protein and calories support skin integrity and healing. Flag patients with poor intake, unintended weight loss, or restricted diets for a dietitian referral, and document intake honestly. Nutrition is easy to overlook on a busy unit, but it belongs in the prevention plan.
Document, Communicate, and Escalate
A prevention plan only works if the next nurse can see it, continue it, and know when it changed.
Documentation should make the plan visible: the risk score and date, skin findings with location and stage if an injury is present, the repositioning schedule, the support surface in use, and any device precautions. Stage descriptions matter for accuracy. Stage 1 is non-blanchable erythema of intact skin; Stage 2 is partial-thickness loss with exposed dermis. If you are uncertain of the stage or see deep tissue discoloration, describe what you observe and involve the wound care nurse rather than guessing.
Use handoff to carry the plan forward. Name the patient's risk level, the prevention measures in place, and any skin changes since the last shift. When you find a new or worsening injury, escalate per facility policy: notify the provider, consult wound care, and reassess the support surface and turning plan. Never change the plan of care unilaterally; work within your facility's protocols and consult resources.
Carry Prevention Through Discharge
Prevention does not end when the patient stabilizes. Education improves compliance and reduces incidence, so teach the patient and family before discharge. Cover why repositioning matters, how to inspect skin daily and what early warning signs look like, how to keep skin clean and dry, and the importance of nutrition and hydration. For patients going home with limited mobility, confirm they have the equipment and home support to keep offloading pressure. A few minutes of clear teaching at discharge can prevent a readmission and protect the gains made during the stay.