5 Pressure Injuries (Bedsores) Nursing Care Plans

Pressure injuries start the moment a patient stops moving and nobody moves them. Skin and soft tissue get compressed between a bony prominence and a hard surface, small vessels collapse, perfusion drops, the tissue goes hypoxic, and cells die. Add friction, shear, and moisture and the breakdown accelerates. These wounds drive pain, infection, sepsis, and death, and most of them are preventable at the bedside.

The NPIAP defines a pressure injury as localized damage to skin and underlying soft tissue, usually over a bony prominence or under a medical device. It may be intact skin or an open ulcer, and it may or may not hurt. "Pressure injury" replaced decubitus ulcer and pressure sore because open ulceration does not always happen.

Capillary filling pressure runs about 32 mm Hg, and the pressures over loaded bony prominences routinely exceed that. About one million pressure injuries occur in the United States each year, and roughly 60,000 people die of complications. Older adults admitted for nonelective orthopedic procedures carry even higher risk than other inpatients.

Staging

Stage by what tissue is exposed. Necrotic tissue or eschar has to come off before you can stage accurately, and Stage 1 is easy to miss in darkly pigmented skin (use a penlight or look for warmth, edema, and induration).

• Stage 1: nonblanchable erythema of intact skin.
• Stage 2: partial-thickness skin loss with exposed dermis; presents as an abrasion or blister, wound bed viable, pink or red, and moist.
• Stage 3: full-thickness skin loss into subcutaneous tissue, down to but not through fascia; slough, undermining, and tunneling may be present.
• Stage 4: full-thickness skin and tissue loss with exposed muscle, bone, or supporting structures; undermining and tunneling common.
• Unstageable: full-thickness loss with the base obscured by slough or eschar.
• Deep tissue injury: persistent nonblanchable deep red, maroon, or purple discoloration, or a blood-filled blister, from pressure damage to underlying tissue.

The staging system does not imply injuries march from Stage 1 to Stage 4 or heal in reverse order. A single wound can show multiple stages at once.

Nursing Care Plans and Management

Stages 1 through 3 are managed with aggressive local wound care and nutrition support. Stage 4 usually needs surgery. Planning targets the contributing factors behind poor perfusion, the extent of the wound, and prevention of further breakdown.

Nursing Problem Priorities

1. Assess and stage injuries accurately.
2. Relieve and redistribute pressure.
3. Optimize wound care and healing.
4. Manage pain.
5. Prevent and treat infection.
6. Address immobility and poor nutrition.
7. Educate patient and caregiver on self-care and prevention.
8. Monitor for complications such as cellulitis or deep tissue damage.
9. Reassess and document on a schedule, working with the full team.

Nursing Assessment

Assess for the following subjective and objective data:

• Destruction or disruption of skin layers and surfaces
• Drainage of pus
• Invasion of deeper body structures
• Current stage and wound bed characteristics (see Staging above)

Nursing Diagnosis

Form the diagnosis from your assessment and clinical judgment. Diagnostic labels matter less than the priorities they drive, so anchor the plan to the patient's actual breakdown risk and wound status rather than the label.

Nursing Goals

• The patient receives stage-appropriate wound care and has risk factors controlled.
• Existing injuries heal and pressure is reduced.
• Patient and caregiver verbalize understanding of home care: nutrition, pressure relief, wound care, and incontinence management.
• Patient and caregiver cope with the situation and provide support and monitoring.
• The patient maintains stable weight or progresses toward the weight goal and stays free of malnutrition.
• The patient verbalizes the link between malnutrition and pressure injury and joins interventions to improve intake.
• No further preventable injuries develop.

Nursing Interventions and Actions

1. Assessing and Staging Pressure Injuries

1. Assess specific risk factors. Patients with existing injuries stay at risk for more. Drivers include sustained pressure from body weight or a device, increased arteriole pressure, shear, friction, moisture, and poor nutrition.

2. Note age and skin condition. Older skin is less elastic, drier, thinner, and less padded, with a flattened dermal-epidermal junction and reduced vascularity. Poor skin quality lowers the pressure needed to ulcerate.

3. Assess nutritional status: weight, weight loss, serum albumin. Severe protein depletion shows an albumin less than 2.5 g/dL. Patients with pressure injuries lose large amounts of protein in wound exudate and may need 4000 kcal/day or more to stay anabolic. Malnutrition, hypoproteinemia, and anemia make tissue vulnerable and delay healing.

4. Screen for chronic disease (diabetes mellitus, AIDS, Guillain-Barré, peripheral and cardiovascular disease). These stack risk factors: poor nutrition and hydration, incontinence, immobility, and sensory deficits that blunt the pressure-feedback response.

5. Inspect skin on admission and daily. Breakdown rises directly with the number of risk factors present. Prevention starts with history, a risk assessment, and a full skin exam at admission.

6. Ask about radiation therapy. Irradiated skin is thin, brittle, and poorly perfused. Skin renews about every 26 days, which makes it especially vulnerable to ionizing radiation injury.

7. Check awareness of pressure sensation. People normally shift off pressure points every few minutes, even asleep. Patients with decreased sensation do not, so they sit in sustained pressure until ischemic damage is done.

8. Assess for fecal and urinary incontinence. Urea converts to ammonia within minutes and erodes skin; stool enzymes break it down further. Plastic-lined pads trap moisture, and soiling seeds bacteria into open wounds.

9. Assess mobility (shifting weight, turning in bed, bed-to-chair transfers). Immobility is the single biggest inpatient risk factor. Neurologically impaired, sedated, restrained, or post-trauma patients cannot offload pressure often enough.

10. Assess for moisture (perspiration, humidity, drainage, fistula). Continuous moisture macerates skin.

11. Assess shear and friction. Shear shows up over the sacrum, scapulae, heels, and elbows from semi-Fowler's positioning, repositioning, and lift sheets. Skin tears and deepithelialization open the barrier to contamination and water loss.

12. Assess the surface the patient spends most time on (mattress or wheelchair cushion). Anyone on one surface most of the day needs a pressure-reduction or pressure-relief device. Match the surface to the patient's risk and care plan.

13. Inspect skin over bony prominences: sacrum, trochanters, scapulae, elbows, heels, inner and outer malleolus, inner and outer knees, occiput. Supine, the highest pressures hit the sacrum, heel, and occiput (40 to 60 mm Hg). Prone, the chest and knees take the load (50 mm Hg). Seated, the ischial tuberosities bear the most (100 mm Hg). All exceed end-capillary pressure, which is why these sites break down first.

14. Use a validated risk tool: Braden, Norton, or Waterlow. The Braden scale is the most widely used; its six subscales are activity, mobility, moisture, nutrition, sensory perception, and friction. Norton covers physical condition, mental state, activity, mobility, and incontinence. Lower scores mean higher risk. Waterlow, common in the UK and Ireland, adds BMI, skin type, sex/age, continence, mobility, appetite, medications, and special risks such as malnutrition, neurological deficit, and major surgery or trauma.

15. Assess pain, especially around dressing changes. Premedicate when indicated. Pain is often absent in paraplegic or critically ill patients but can be chronic and worsened by wound exams. IV or oral analgesia may be needed for an adequate look.

16. Stage the injury at every dressing change. Staging drives treatment. An eschar-covered wound cannot be staged until the necrotic tissue is removed.

17. Read the wound bed.

• Necrotic tissue: dead tissue (black, brown, leathery, or white) that must come off before healing or accurate staging.
• Color: signals viability and oxygenation. White, gray, or yellow eschar can appear in Stage 2 and 3; black eschar in Stage 4. Deep tissue injury shows persistent nonblanchable deep red, maroon, or purple.
• Odor: may come from infection or necrotic tissue. Distinguish wound odor from odors created by local products.
• Exposed bone, joint, or muscle: seen at the base of Stage 4 wounds. Muscle is least resistant to pressure and dies before the skin breaks down, so a small skin opening can sit over a large cavity.

18. Measure length, width, and depth, and probe for undermining. Ulcers start in deep tissue, so the skin opening underrepresents the true size. A small surface defect can hide extensive undermining.

19. Assess wound edges and surrounding tissue. Healthy margins are needed for adhesive products and mark the wound boundary. Rolled edges (epibole) typically appear in Stages 3 and 4.

20. Assess exudate. Normal exudate contains serum, blood, and white cells and runs clear, cloudy, or blood-tinged; pus signals infection. Drainage is excessive when dressings need changing more often than every 6 hours.

21. Track healing with the PUSH tool. This NPIAP tool standardizes measurement by scoring surface area, exudate amount, and wound tissue type.

2. Wound Care and Promoting Skin Integrity

1. Use pressure-relieving surfaces: specialized mattresses, cushions, heel troughs. Dynamic systems use an energy source to alternate pressure points; static systems redistribute pressure over a larger area without one.

2. Reposition frequently. Turning is the cornerstone of prevention and treatment. Patients who can shift their own weight should do so every 10 minutes; reposition everyone else every two hours, even on a specialty surface.

3. Feed a well-balanced diet built with a dietitian. Malnutrition is one of the few reversible contributors, and adequate intake measurably improves healing.

• Protein builds and repairs tissue, supports immune function and clotting, and offsets nitrogen lost in exudate. Sources: lean meats, poultry, fish, eggs, beans, dairy.
• Vitamin C drives collagen synthesis, activates leukocytes and macrophages, improves tensile strength, and aids iron absorption. Sources: citrus, berries, tomatoes, leafy greens.
• Zinc supports healing, immune function, and collagen formation. Sources: oysters, beef, chicken, beans, eggs, nuts. Megadoses inhibit healing and cause copper deficiency, so dose with the dietitian.
• Iron carries oxygen and supports collagen formation. Heme sources: lean meats, poultry, fish. Non-heme: beans, nuts, leafy greens.

4. Provide local wound care by stage. Stages 1 and 2 are usually conservative; Stages 3 and 4 may need surgery.

Stage 1:

• Apply a flexible hydrocolloid or vapor-permeable membrane dressing to hold a moist wound bed and block bacteria while protecting fragile granulation tissue.
• Apply a vitamin-enriched emollient each shift to restore barrier function and hydration. An Australian trial in older adults found nearly a 50% reduction in skin tears with twice-daily emollient.

Stage 2:

• Alginates for moderate-to-heavy exudate; they gel on contact with drainage. Do not use on dry or minimally draining wounds (they dehydrate the bed and delay healing).
• Hydrocolloids or vapor-permeable membrane to promote healing and debridement; avoid on heavily exuding wounds.
• Gauze with normal saline holds moisture but needs frequent changes and removal while still wet; provides dead-space obliteration and mechanical debridement.
• Hydrogels rehydrate dry, sloughy, or necrotic wounds and support autolytic debridement; best on shallow, low-exudate wounds.

Stage 3 and 4:

• Foams: best on granulating wounds; absorb exudate, cut odor, repel bacteria and water.
• Gauze with normal saline: as for Stage 2. Normal saline remains the preferred cleanser.
• Wound fillers: pastes, granules, or powders that pack the wound, hold moisture, and support autolytic debridement; need a secondary dressing.
• Autolytic debridement: a hydrocolloid or hydrogel creates a moist interface so the body's proteolytic enzymes liquefy and separate necrotic from healthy tissue.
• Sharp or surgical debridement: removes necrotic tissue and senescent cells; nonselective, so it demands skill and judgment.
• Mechanical debridement: wet-to-dry dressings, whirlpool, or forceful irrigation loosen and pull off necrotic tissue.
• Electrical stimulation: pulsed direct or indirect current; recommended in multiple clinical practice guidelines.
• Biosurgery: live blowfly larvae for fast debridement; effective in chronic ulcers.
• Topical growth factors: nerve, colony-stimulating, and fibroblast growth factors. The recombinant human platelet-derived growth factor becaplermin is US FDA-approved for lower-extremity diabetic neuropathic ulcers extending into subcutaneous tissue or beyond.
• Negative pressure wound therapy: subatmospheric pressure that reduces edema, speeds granulation, and stimulates circulation.
• Enzymatic debridement (chlorophyll, collagenase, papain): proteolytic enzymes that digest the collagen anchoring necrotic tissue without harming granulation tissue.

5. Clean with povidone iodine, not hydrogen peroxide. Hydrogen peroxide is toxic to fibroblasts and indiscriminately strips both necrotic material and fragile granulation tissue, so avoid frequent or long-term use.

6. Irrigate open wounds with normal saline when no germicidal action is needed, and use it as a rinse after other irrigants to limit fluid shifts and drying in new tissue.

7. Offload when supine. Minimally elevate head and shoulders on one pillow or a foam wedge to cut shear and keep the sacrum and ischial tuberosities off the bed frame; use a wedge cushion to protect the heels.

3. Promoting Infection Control and Preventing Infections

Open ulcers are a direct entry for bacteria, and sacral wounds sit close to the perineum. Poor nutrition weakens the immune response. In patients with sepsis and pressure injuries, the sepsis usually traces to a urinary tract infection.

1. Assess nutritional status. Patients who are severely malnourished are prone to wound infection and may need 4000 kcal/day or more to stay anabolic. Poor nutrition feeds the chronicity of these wounds.

2. Consider the wound in any unexplained sepsis. During a septic workup, treat the pressure injury as a possible source. Most are already draining, but a thick eschar that blocks drainage may need debridement to prevent systemic infection.

3. Manage incontinence. Sacral wounds carry the highest contamination risk from urine and stool. Continuous moisture macerates skin, and soiling introduces bacteria into the wound.

4. Assess odor, tissue color, and drainage. Foul odor and gray-yellow tissue without pink granulation suggest infection. Clear to straw-colored exudate is normal; large amounts of purulent green or yellow drainage indicate infection.

5. Check temperature. Fever is a temperature above 100.4°F (38°C) and signals infection unless the patient is immunocompromised or diabetic. In spinal cord injury, a delayed fever workup worsens tissue damage and outcomes.

6. Monitor WBC. An elevated count points to infection, though in older adults the count may rise only slightly because of diminished marrow reserve. A CBC with differential helps confirm.

7. Culture when indicated. All pressure injuries are colonized; not all are infected. Suspect infection with copious foul-smelling purulent drainage, fever, increased pain, and a bacterial count greater than 10⁵. Use tissue biopsy, not swab cultures, to distinguish contamination from true tissue invasion.

8. Watch for osteomyelitis. Suspect bone infection with an elevated ESR, elevated WBC, abnormal pelvic films, or a Stage 4 wound with exposed bone. Confirmed osteomyelitis needs a prolonged antibiotic course.

9. Consult a dietitian for a high-protein, high-calorie diet to support healing and immune function. Malnutrition is reversible, and adequate intake improves healing.

10. Provide perineal hygiene after every incontinence episode. Keep the skin around the wound clean and free of urine and feces, and identify and treat reversible causes of incontinence.

11. Provide hydrotherapy when indicated. Whirlpool or pulse lavage irrigates and mechanically debrides to build a bed of well-granulated tissue.

12. Match wound care to stage and infection. Stage 1 can take a transparent film; Stage 2 needs a moist environment; Stage 3 and 4 care hinges on necrotic tissue.

13. Use infection control: hand hygiene and PPE. Glove and gown for perineal and wound care; perform hand hygiene before and after every procedure.

14. Administer antibiotics as prescribed. Cellulitis or sepsis needs systemic therapy. Oral antibiotics or topical silver sulfadiazine can work; empiric coverage should be broad, hitting aerobic gram-positive and gram-negative organisms and anaerobes.

15. Provide discharge instructions to patient and family. Plan early with the interdisciplinary team, and teach prevention and treatment using charts, diagrams, photos, and videos.

16. Prevent incontinence-related breakdown. Manual disimpaction and stool-bulking agents relieve overflow fecal incontinence; a bowel and bladder regimen, constipating agents, and a low-residue diet help when no treatable cause exists.

17. Use diapers and pads correctly. They pull moisture off the skin only if checked often and changed when soiled; left in place they worsen maceration and dermatitis.

18. Obtain tissue biopsy for wounds that do not improve despite adequate care or that suggest tissue invasion. Bone biopsy is the criterion standard for osteomyelitis in a pressure injury.

19. Prepare the patient for debridement to remove necrotic tissue, eschar, and slough. The three methods are enzymatic, mechanical, and sharp debridement.

20. Choose the right cleansing solution. Povidone iodine covers bacteria, spores, fungi, and viruses; dilute it and stop once granulation begins. Acetic acid (0.5%) targets Pseudomonas aeruginosa but can discolor tissue and mask superinfection. Sodium hypochlorite (2.5%) is mainly for debriding necrotic tissue.

21. Apply topical antibiotics before debridement as prescribed. Silver sulfadiazine offers broad coverage, low toxicity, and minimal pain. Mafenide penetrates eschar and softens it before debridement.

22. Monitor for antibiotic resistance. Watch for nonhealing despite therapy and follow culture and sensitivity results closely.

4. Empowering the Patient and Promoting Adherence

Patients face adherence barriers from impaired function, no prior experience with wound care, and the long horizon of pressure management. Local wound care often continues at home for weeks to months.

1. Assess the patient's and caregiver's ability to provide wound care. Family members are rarely trained for this, and knowledge and attitude track with actual prevention practice.

2. Assess understanding of prevention. Immobile patients need frequent repositioning to protect intact skin; impaired mobility is the most common reason patients sit in injurious pressure.

3. Set expectations on healing time. Even under ideal conditions, injuries take weeks to months. Wounds heal from the base up and the edges in, through three overlapping phases: inflammation, proliferation, and remodeling. Palliative wound care fits clean, chronic, nonhealing wounds.

4. Connect incontinence to breakdown. Continuous moisture macerates skin and soiling seeds bacteria; managing incontinence is often the hardest part of home care and a frequent reason for nursing home placement.

5. Teach a high-calorie, high-protein diet. Some patients need enteral feeding (gastrostomy or nasogastric tube, or oral). Discuss risks and benefits first, and respect cultural and religious values around artificial nutrition.

6. Arrange a pressure-relief surface for home. Options range from a dense foam mattress to rented low-air-loss beds (KinAir, Flexicare) and air-fluidized beds (FluidAir, Skytron, Clintron). These are heavy, costly, hard to clean, and often not covered by payers.

7. Teach infection warning signs to report: fever, malaise, chills, foul odor, purulent drainage. Infection can be local (cellulitis, osteomyelitis) or systemic (septicemia, with mortality greater than 50%).

8. Teach incontinence management: moisture-barrier ointments, underpads, external catheters. The WOCN recommends skin barriers (creams, ointments, pastes, film-forming protectants) to keep intact skin intact.

9. Teach wound care with a return demonstration. Immediate feedback corrects technique before it becomes habit. Protect surrounding skin from moisture and friction, and change dressings as soon as they are soiled.

10. Provide written instructions and resources. Spell out who provides care, how often, and what supplies are needed, individualized and kept on hand.

11. Involve a social worker or case manager. Many patients are older and rely on an older spouse, so home discharge can be unrealistic; home health visits ease the transition and sustain prevention.

12. Consult a wound specialist for home care. They evaluate the care setting, secure specialty treatment, and teach the family to recognize infection.

13. Teach pressure reduction and relief: turning schedule, specialty beds, relief surface for sitting. Per the WOCN, set the repositioning schedule against the patient's condition and the support surface in use.

14. Discuss respite care. Long-term home caregiving is heavy; caregivers need to see their own rest as part of sustaining the patient's care, not as avoiding it.

15. Discuss in-home nursing or homemaker services. Keeping the patient at home lowers hospital-acquired infection risk and keeps them in familiar surroundings. Coordinated transmural and hospital-in-the-home care can shorten healing and reduce readmissions.

16. Arrange followup. Visit every three weeks for the first several months, then every six months, then yearly. Early issues include sutures, drain removal, and clearance to sit up or exercise.

17. Teach the caregiver to document healing. Concise measurement supports management; photography and diagrams are the most common methods.

18. Teach home repositioning. Avoid long uninterrupted pressure for good. Seated patients with upper-extremity function should lift off the wheelchair for at least 10 seconds every 10 to 15 minutes; patients in bed should be repositioned at least every two hours.

5. Promoting Optimal Nutrition Status

Nutrition drives both prevention and healing. The 2019 EPUAP, NPIAP, and PPPIA guidelines direct teams to weigh impaired nutrition status in pressure injury risk.

1. Screen nutrition on admission. Any trained team member can screen, and acute care facilities screen within 24 hours of admission. A validated tool flags risk even when weight and height are hard to obtain, and a registered dietitian follows up.

2. Obtain weight and BMI on admission. Low body weight and unplanned weight loss are major risk factors for malnutrition and breakdown. Obesity also raises risk through hypovascularity, reduced mobility, and difficulty self-repositioning.

3. Review usual caloric intake and food choices to find gaps and tailor teaching. Undernutrition cuts calories, protein, vitamins, and minerals; overnutrition pushes toward overweight and obesity.

4. Assess body composition. It is an independent risk factor for malnutrition and sarcopenia. Tracking it over time can reveal lost body mass and sarcopenic obesity, which is common in immobile, undernourished patients.

5. Set a weight goal with the dietitian. Provide 30 to 35 kcal/kg per day for malnourished adults or those at risk.

6. Provide adequate kilocalories rich in unsaturated fat. Calories spare protein for tissue repair. Fat is the most concentrated energy source, cushions bony prominences, insulates, and carries the fat-soluble vitamins A, D, E, and K.

7. Increase energy and protein intake. When carbohydrate and fat fall short, the body degrades protein and lean mass, which compromises healing. One study recommends increasing energy intake by 50% above baseline and protein to 1.5 g/kg per day.

8. Encourage fluids as tolerated. Water carries minerals, vitamins, amino acids, and glucose into and out of cells. Food accounts for 19% to 27% of total fluid intake in healthy adults.

9. Give oral nutritional supplements as indicated. Patients with chronic disease or pressure injuries often cannot meet protein and calorie needs by mouth alone; supplements help close the gap.

10. Assist with enteral or parenteral nutrition. When healing stalls and oral intake is inadequate, consider enteral feeding if it fits the patient's goals of care. Use parenteral nutrition when enteral cannot meet requirements.

11. Counsel on affordable, accessible food. For patients who cannot cook or afford supplements, suggest small frequent meals and snacks such as high-calorie bars, sandwiches, Greek yogurt, homemade milkshakes, and instant breakfasts.

12. Refer to support and education programs. Lifestyle skills programs and telephone-based education produce short-term gains in knowledge and quality of life for patients with ongoing risk.

13. Offer written nutrition materials to reinforce teaching. A simple evidence-based pamphlet ("Eat plenty of protein") improved risk-factor knowledge in community-dwelling older adults.