Pressure Injury Prevention on the NCLEX
Repositioning schedules, support surfaces, nutrition, and heel protection.
Preventing a pressure injury is cheaper than treating one in every currency: skin, money, and exam points.
Repositioning
Turn bedbound patients at least every 2 hours; chairbound patients shift weight every hour, or every 15 minutes if they can do it themselves. Use the 30-degree lateral position rather than side-lying directly on the trochanter. Keep the head of bed at or below 30 degrees when the condition allows: higher elevations create shear as the body slides. Lift, never drag: use the drawsheet or lift equipment. Pillows between bony surfaces (knees, ankles).
Surfaces and heels
High-risk patients go on a pressure-redistribution mattress or overlay; a standard hospital mattress is not prevention. Chair cushions for sitters. No donut-shaped devices: they concentrate pressure in a ring. Float the heels: pillow under the calves so the heels hang free, or heel-suspension boots. The heel has almost no subcutaneous padding and deteriorates fast in immobile, diabetic, and vascular patients.
Risk scoring and skin checks
The Braden scale rates sensory perception, moisture, activity, mobility, nutrition, and friction/shear; 18 or below flags risk in adults, and lower means worse. Reassess on schedule and with any change. Head-to-toe skin inspection every shift for high-risk patients, with attention to sacrum, heels, occiput, and under devices (tubing, masks, casts, prongs). Nonblanchable redness is already a stage 1 injury, not a warning shot. Do not massage reddened bony prominences: it damages compromised tissue. Manage moisture: barrier cream for incontinence, dry linens, no layers of pads that trap heat.
Nutrition
Skin holds together with protein. Assess intake, weight trend, and albumin/prealbumin context; involve dietitian early. Adequate calories, protein, and fluids are part of the prevention order set, not an afterthought. A low Braden nutrition subscore is an intervention trigger by itself. Staging of established wounds is its own topic; know it separately.
Frequently asked
Redness over the sacrum that does not blanch?
Stage 1 pressure injury. Offload it now, document, and escalate the prevention plan. Do not massage it.
Why keep the head of bed at 30 degrees or less?
Shear. Above 30 the torso slides down and drags the sacral skin against the deeper tissue.
Can turning be delegated?
Yes, repositioning is delegable to assistive personnel. The skin assessment behind it stays with the nurse.
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