1. Rapid Summary
A pressure injury (formerly known as a pressure ulcer) is localized damage to the skin and underlying soft tissue, usually over a bony prominence, resulting from prolonged pressure or pressure combined with shear or friction. Because treating deep pressure injuries is complex and costly, the NCLEX heavily prioritizes proactive, evidence-based preventive nursing care. Ensuring skin integrity is a fundamental metric of quality patient care.
2. High-Yield Points/Must Know
| Critical Prevention Area | Essential Nursing Guideline & Rationale |
|---|---|
| Repositioning Frequency | Change the client's position at least every 2 hours when in bed, and at least every 15 to 30 minutes or hourly when sitting in a chair. |
| The 30-Degree Rule | When positioning a client laterally, use the 30-degree lateral position. Avoid placing the client directly on their trochanter (hip bone) at a 90-degree angle, which creates extreme pressure peaks. |
| Shear Minimization | Keep the head of the bed (HOB) elevated at 30 degrees or less unless contraindicated (e.g., during meals or tube feedings) to prevent the client from sliding down, which causes shearing forces on the sacrum. |
| Device Integrity | Regularly inspect skin underneath medical devices (e.g., oxygen tubing, cervical collars, restraints, sequential compression sleeves) at least once per shift. |
3. Mnemonics
Remember the SKIN protocol to systematically eliminate pressure injury risk factors:
- S - Surface Selection: Use pressure-redistributing mattresses (e.g., air, gel, or foam overlays). Never use donut rings.
- K - Keep Moving: Adhere strictly to the 2-hour turning schedule in bed and use heel-floating techniques.
- I - Incontinence & Moisture Management: Clean the skin immediately after fouling. Apply an un-medicated moisture barrier ointment to shield the stratum corneum.
- N - Nutrition Optimization: Ensure high-protein, high-calorie intake with adequate hydration to maintain cellular turgor and tissue repair capacity.
4. Most Tested Facts
The Braden Scale:
The Braden Scale is the most widely tested tool used to predict pressure injury risk. It assesses 6 categories: Sensory Perception, Moisture, Activity, Mobility, Nutrition, and Friction/Shear.
- Scoring Trap: The total score ranges from 6 to 23. The LOWER the score, the HIGHER the risk.
- A score of <= 18 generally indicates the threshold for initiating standard pressure injury prevention protocols in an adult client.
Heel Elevation ("Floating"):
- The heels are one of the most common sites for deep tissue pressure injuries.
- Correct Technique: Place a pillow lengthwise under the client's calves to completely lift or "float" the heels off the mattress surface.
- Incorrect Technique: Placing a small rolled towel or pillow directly under the ankles or heels, which simply shifts the localized pressure point rather than eliminating it.
5. Clinical Correlation
An 81-year-old immobile client with fecal incontinence and severe protein-calorie malnutrition is admitted following a femoral neck fracture.
- Wrong Action: Massaging red areas over the sacrum to "stimulate blood flow," keeping the HOB at 60 degrees so they can watch TV comfortably, and sliding them up in bed by pulling on their arms.
- Correct Action: Assess the Braden score immediately. Implement a strict 2-hour turning log using the 30-degree lateral tilt. Use a mechanical lift or a draw-sheet with a minimum of two staff members to lift and reposition the client (eliminating friction and shear). Cleanse the perineal area immediately after incontinent episodes with a pH-balanced cleanser and apply a barrier cream. Request a dietary consultation for protein supplementation.
6. Frequently Tested
- Massaging Bony Prominences: Never massage reddened or bony areas (like the trochanter, sacrum, or calcaneus). Massage causes deep tissue ischemia, micro-tears in fragile capillary beds, and accelerates the development of Stage 1 or deep tissue injuries.
- Nutrition Markers: Monitor laboratory values that dictate wound healing and skin maintenance. Look for deficits in Serum Albumin (normal: 3.5--5.0 g/dL) and Prealbumin (normal: 15--36 mg/dL). Prealbumin is the most accurate indicator of current acute nutritional status due to its short half-life.
- Skin Inspection Frequency: Perform a comprehensive, head-to-toe skin assessment at least once every 24 hours, or more frequently depending on facility policy and high-risk status (e.g., in critical care).
7. Common NCLEX Trap
- Trap: An option suggests placing a synthetic "donut-shaped" cushion under a wheelchair-bound client to relieve sacral pressure.
- Reality: False. Donut rings or ring cushions are strictly contraindicated. They restrict local capillary blood flow and cause a ring of constriction that worsens ischemia to the central tissue area.
- Trap: Assuming that because a client has an advanced air-fluidized or alternating-pressure bed, the nurse no longer needs to manually turn them every 2 hours.
- Reality: False. Specialized pressure-relieving surfaces complement nursing care; they do not replace the physiological necessity of regular manual turning and positioning.
- Trap: Using hot water and scrubbing vigorously with standard alkaline hand soap to clean an incontinent elderly client's perineum.
- Reality: False. Hot water and harsh soaps strip natural sebum lipids, drying out the skin and creating micro-fissures. Use lukewarm water and mild, non-alkaline, no-rinse cleansing foams.
8. Mini Questions
Question 1: The nurse is calculating the Braden Scale score for a newly admitted alert client who has paraplegia and is completely incontinent of urine. The nurse calculates a total score of 12. How should the nurse interpret this result?
A. The client is at minimal risk; standard nursing care is sufficient.
B. The client is at high risk for developing a pressure injury.
C. The assessment tool is invalid because the client has paraplegia.
D. The higher score indicates excellent skin integrity defenses.
- Answer: B
- Explanation: On the Braden Scale, lower scores indicate higher risk. A total score of 12 represents a high risk for pressure injury development, requiring immediate implementation of an aggressive prevention care plan (turning schedules, specialty mattress, barrier creams).
Question 2: The nurse is positioning a bedridden client to relieve pressure on the sacrum and trochanter. Which positioning technique is most appropriate for the nurse to utilize?
A. Maintain the head of the bed at a 60-degree angle.
B. Place the client in a 30-degree lateral tilt position using foam wedges.
C. Turn the client directly onto their side at a 90-degree angle to the mattress.
D. Place a soft donut cushion directly underneath the client's buttocks.
- Answer: B
- Explanation: The 30-degree lateral position tilts the client slightly off the sacrum without putting the full weight of the body directly onto the greater trochanter (which occurs at 90 degrees). High-Fowler's (60°) causes shear, and donut cushions cause venous ring constriction.
Question 3: While performing a skin assessment on an immobile older adult client, the nurse notes a localized, non-blanchable area of redness over the sacrum. The skin is completely intact. Which action should the nurse take?
A. Massage the red area firmly for 2 to 3 minutes to improve perfusion.
B. Apply a warm, moist heating pad to the area to vasodilate blood vessels.
C. Cleanse the area with an alcohol-based rub to dry out the skin.
D. Avoid massaging the area and document it as a Stage 1 pressure injury.
- Answer: D
- Explanation: Intact skin with non-blanchable redness is the definitive hallmark of a Stage 1 pressure injury. Massaging this area is strictly contraindicated because it tears underlying capillaries and accelerates deep tissue damage. Heat pads and alcohol rubs increase tissue degradation.
Question 4: The nurse is planning care for a malnourished client who is at risk for skin breakdown. Which laboratory value should the nurse monitor as the most sensitive indicator of the client's current, acute nutritional status for tissue maintenance?
A. Serum Albumin
B. Prealbumin
C. Total Cholesterol
D. Hemoglobin
- Answer: B
- Explanation: Prealbumin has a very short half-life (around 2 days), making it a highly sensitive and reliable indicator of acute, current nutritional status and protein synthesis. Serum albumin has a half-life of 20 days, reflecting long-term nutritional patterns rather than immediate changes.
Question 5: The nurse assists a client to move up in bed. Which action by the nurse is essential to prevent tissue damage caused by shearing forces?
A. Pull the client up smoothly by grabbing their wrists.
B. Sprinkle baby powder or cornstarch liberally across the sheets to reduce drag.
C. Use a draw-sheet or friction-reducing slide sheet to lift the client completely off the mattress.
D. Instruct the client to keep their legs completely straight during the move.
- Answer: C
- Explanation: Shearing occurs when the skin remains stationary against the sheet while the underlying bony structure shifts. To eliminate friction and shear, the nurse must use a lift sheet or slide sheet along with another staff member to physically lift the client's body mass clear of the mattress rather than dragging them across it.
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9. Key Takeaway Box
Key Takeaway: Pressure injury prevention is built on eliminating pressure, moisture, and shear. Turn bed-bound clients every 2 hours using a 30-degree lateral tilt, and float the heels completely off the mattress. Remember that lower Braden scores (<= 18) mean higher risk. Never massage a reddened area, avoid donut cushions, keep the HOB <= 30° to prevent shear, and prioritize prealbumin as your acute nutritional marker for healing.
