How to Prevent Pressure Injuries: A Practical Guide for Healthcare Teams

Pressure injuries—also called pressure ulcers, bedsores, or decubitus ulcers—are among the most common, costly, and preventable harms in health care. They form when sustained pressure on the skin and underlying tissue goes unrelieved, and they cause serious pain, prolong hospital stays, and increase mortality risk. The good news is that prevention is neither mysterious nor expensive. Decades of clinical evidence point to a small set of interventions that work reliably when applied together: risk assessment, scheduled repositioning, appropriate support surfaces, daily skin care, and adequate nutrition.

This article explains each step in the order that matters clinically, gives the reasoning behind it, and highlights what to consider when selecting beds and surfaces for patient units. The guiding principle is simple: keep the pressure off before it damages the tissue.

Why Pressure Injuries Develop

A pressure injury is caused by localised mechanical deformation of soft tissue trapped between a bony prominence and a firm external surface. When the interface pressure exceeds capillary closing pressure—roughly 32 mmHg—blood flow to the area slows and eventually stops. If the tissue stays ischaemic long enough, cells die and the skin breaks down.

Pressure alone, however, is only part of the problem. Shear occurs when deep tissue layers slide relative to the skin, such as when a patient in a semi-recumbent bed slides downward while the sacral skin stays against the mattress. Shear angulates and stretches blood vessels and can close off flow at pressures far below 32 mmHg. Friction strips the protective outer layer of skin, while moisture from perspiration, urine, or stool macerates the skin and lowers its tolerance to both pressure and shear.

The practical consequence is that no single device or action prevents pressure injuries. A high-end mattress is ineffective if the patient never moves; repositioning alone cannot compensate for severe malnutrition or an unsuitable surface. Effective prevention addresses all four forces together.

Assess Risk Early and Systematically

Prevention begins with identifying which patients are at risk. A structured tool such as the Braden Scale, the Norton Scale, or the Waterlow Score should be completed on admission and repeated at intervals, not treated as a one-time formality.

Higher risk scores should lead to stronger prevention bundles: shorter repositioning intervals, a more advanced support surface, daily skin inspection, and tighter nutritional monitoring. Reassessment is equally important; risk changes after surgery, during fever, or when mobility declines, and the plan should change with it.

Reposition Patients on a Written Schedule

Repositioning is the single most effective intervention for preventing pressure injuries. The logic is simple: pressure only becomes damaging when it is unrelieved. Changing the patient's position regularly redistributes load, restores blood flow, and gives compressed tissue time to recover.

For adults confined to bed, reposition at least every two hours. Patients who can sit up should shift their weight every 15 to 30 minutes during the day, or perform pressure-relief lifts if they have sufficient upper-body strength. The interval must always be individualised: if a skin check after two hours reveals new redness, that patient needs a shorter interval.

Technique matters as much as frequency. Use the 30-degree lateral tilt rather than a 90-degree side-lying position, which concentrates pressure on the greater trochanter. Keep the head of the bed at 30 degrees or less whenever clinically safe, because higher elevations increase shear on the sacrum. Suspend the heels by placing a pillow lengthwise under the lower calves. Lift rather than drag: use slide sheets, transfer boards, or a mechanical lift to avoid friction injuries.

Equipment choice directly affects how well this works. A bed with electric height adjustment lets caregivers set the working height for their own body, eliminating the awkward reaching that leads to sliding patients instead of lifting them. This is one reason height-adjustable hospital beds are increasingly recommended for units with high-acuity or immobile patients.

Choose the Right Support Surface

Support surfaces form the second pillar of prevention. They redistribute the patient's weight over a larger contact area, lowering peak pressures under bony prominences. No support surface removes pressure entirely, and none replaces repositioning. What a good surface does is buy time—more margin for tissue between turns.

Reactive and active surfaces differ in ways that matter for purchasing. Reactive surfaces such as high-density or viscoelastic foam conform to the body and increase contact area. Active surfaces such as alternating-pressure mattresses cycle pressure across zones, shifting weight-bearing areas periodically. Low-air-loss and air-fluidised beds add moisture management and are used for the highest-risk patients.

When selecting beds for a ward with at-risk patients, articulation and positioning range are clinical features. A bed that cannot raise the backrest, adjust the leg section, or change height forces staff to wedge pillows and slide patients into position—exactly the movements that create shear and friction.

Multifunctional electric beds are designed around this problem. Independent adjustment of the backrest, thigh section, and height lets caregivers position the patient precisely without dragging the body across the surface, reducing shear load on the sacrum and heels.

Emergency and critical care areas need special attention: patients often remain on firm transport stretchers for hours, and thin padding, forced immobility, and long waits make these high-risk zones for pressure injury.

Emergency and high-acuity beds address this workflow, combining pressure-reducing surfaces with the ability to reposition the patient quickly and avoid a stretcher-to-bed transfer at a fragile moment.

Adjuncts complete the picture. Systematic reviews support prophylactic dressings—multi-layer foam or hydrocolloid dressings over the sacrum and heels—in high-risk patients. Wedges, heel boots, and turning aids are useful additions. The evidence is far less kind to massaging bony prominences, a practice once routine and now widely discouraged.

For hospitals planning bed replacement, the clinical case for equipment that supports prevention is well documented. Our review of the role of electric hospital beds in reducing pressure ulcers explains how bed design and prevention outcomes are linked.

Inspect Skin Daily and Protect It

Skin inspection is the early-warning system of pressure injury prevention. Check the skin at least once daily and at every repositioning, paying particular attention to the sacrum, heels, occiput, elbows, and skin beneath medical devices such as oxygen tubing, catheters, and splints. The earliest sign is non-blanching erythema: a red area that stays red when pressed. On darker skin, look for persistent discolouration, localised warmth, oedema, or hardening. This is a stage 1 injury, and if pressure is removed at this point, tissue usually recovers completely.

Cleanse the skin routinely and after every episode of incontinence. Use a warm, pH-balanced cleanser and pat the skin dry instead of rubbing. Apply a moisturiser to keep the outer layer intact, and use a barrier cream or film for incontinent patients to protect against prolonged moisture. Do not massage bony prominences; the idea that massage stimulates circulation was common for decades, but it offers no benefit and can damage compromised tissue. The best protection is to keep pressure off the skin and keep it clean and dry.

Optimise Nutrition and Hydration

Nutritional status is a decisive part of pressure injury prevention. Skin is metabolically active tissue that needs a continuous supply of protein, energy, and water to maintain structure and repair damage. A malnourished patient cannot maintain healthy skin no matter how careful the repositioning schedule.

For adults at risk, guidelines recommend about 25 to 30 kcal per kilogram per day and 1.25 to 1.5 g of protein per kilogram per day—roughly 30 to 50 percent more protein than the baseline recommendation. Monitor weight routinely; unintentional weight loss of more than 5 percent in one month should trigger a dietitian referral. Hydration matters equally; dehydrated skin is less elastic and more easily damaged.

Nutrition alone does not prevent pressure injuries, and no supplement replaces offloading. But without adequate intake, every other prevention effort operates at a disadvantage.

Pressure injury prevention is a bundle, not a single action:

• Assess risk on admission and whenever the patient's condition changes.
• Reposition on an individualised schedule.
• Place the patient on an appropriate support surface.
• Inspect and protect the skin every day.
• Meet nutritional and hydration needs.

When one element is missing, the others must work harder and the patient carries the risk.

For clinicians, consistency is the defining skill. For administrators and procurement teams, equipment decisions are clinical decisions. Electric positioning, height adjustability, and pressure-redistributing surfaces translate directly into fewer shear events, shorter unrelieved pressure periods, and fewer pressure injuries.

The cost of doing this correctly is small compared with the cost of one full-thickness pressure injury—in patient suffering, treatment expenses, and liability. Start with the risk assessment, build the schedule, and make sure the bed surface is part of the prevention plan rather than a passive piece of furniture.