Pressure Injuries Nursing Guide 2026: NPUAP Staging, Braden Scale, Prevention & Wound Care

⚕️ Medical Disclaimer: This content is for educational purposes only and is intended for licensed healthcare professionals. It does not constitute medical advice and should not replace clinical judgment, facility protocols, or physician orders. Always verify medications, doses, and procedures with your institution's guidelines.

NPUAP 2016 staging system, Braden Scale risk assessment, prevention bundle, wound care principles, and documentation standards for pressure injuries in acute and long-term care.

1. NPUAP 2016 Pressure Injury Staging

2. Common Pressure Injury Sites

3. Braden Scale for Predicting Pressure Sore Risk

6 subscales; each scored 1–3 or 1–4; maximum 23 points. Lower score = higher risk.

Braden Score Risk Levels

4. Pressure Injury Prevention Bundle

Stage	Description	Key Characteristics
Stage 1	Non-blanchable erythema of intact skin	Red skin that does NOT blanch (turn white) when pressed. Skin is intact. May be warm, firm, or tender. Can be harder to detect in darkly pigmented skin — look for color change, warmth, texture difference.
Stage 2	Partial-thickness skin loss with exposed dermis	Shallow open ulcer with red/pink wound bed. May appear as intact or ruptured blister. No slough or bruising. Looks like an abrasion or blister.
Stage 3	Full-thickness skin loss	Full-thickness loss; subcutaneous fat visible but no bone, tendon, or muscle exposed. Slough may be present. May have tunneling or undermining. Depth varies by location.
Stage 4	Full-thickness tissue loss with exposed bone/tendon/muscle	Bone, tendon, or muscle visible or directly palpable. Often has slough or eschar. Tunneling and undermining likely. Osteomyelitis risk significant.
Unstageable	Full-thickness tissue loss, depth obscured by slough/eschar	Cannot determine true depth until slough/eschar removed. Stable, dry, adherent eschar on heels = protective; do NOT remove unless signs of infection (erythema, warmth, fluctuance, purulence).
Deep Tissue Pressure Injury (DTPI)	Persistent non-blanchable deep red, maroon, or purple discoloration	Intact or non-intact skin with deep red/maroon/purple color; may have blood-filled blister; indicates soft tissue injury from pressure/shear before skin breaks down. May evolve rapidly to expose deeper tissue loss.
Medical Device Related PI	Injury from pressure or shear from a medical device	Mirrors shape of device (oxygen mask, nasal cannula, NG tube, cervical collar, SCDs). Stage using same staging system. Prevention: pad under devices; remove and assess q2h if possible.
Mucosal Membrane PI	PI on mucous membranes	Cannot be staged (anatomy different). Caused by medical devices (ETT, NG tube). Document as mucosal membrane PI.

Position	High-Risk Bony Prominences
Supine	Occiput (back of head), scapulae, elbows, sacrum, coccyx, heels (highest risk area in many patients)
Side-lying (lateral)	Ear, acromion process (shoulder), greater trochanter (hip), lateral knee, lateral malleolus (ankle)
Prone	Forehead, nose, chin, ears, clavicles, sternum, iliac crests, knees, toes
Sitting (chair/wheelchair)	Ischial tuberosities (sit bones), coccyx, posterior thighs, backs of knees, heels

Subscale	Range	Lowest Score Description	Highest Score Description
1. Sensory Perception	1–4	1 = Completely limited (unresponsive or limited ability to feel pain over most of body)	4 = No impairment
2. Moisture	1–4	1 = Constantly moist (skin wet almost constantly — sweating, incontinence)	4 = Rarely moist
3. Activity	1–4	1 = Bedfast (confined to bed)	4 = Walks frequently (>2x/day outside room)
4. Mobility	1–4	1 = Completely immobile (no position change without assistance)	4 = No limitations
5. Nutrition	1–4	1 = Very poor (NPO or clear liquids for >5 days)	4 = Excellent (eats most of every meal; supplements)
6. Friction & Shear	1–3	1 = Problem (requires moderate-maximum assist; frequent repositioning; spasticity/contractures)	3 = No apparent problem

Score	Risk Level	Intervention Intensity
15–18	Mild risk	Reposition q2h; moisture barrier; nutritional assessment
13–14	Moderate risk	Above + pressure redistribution surface (foam overlay or gel); heel protection
10–12	High risk	Above + specialty bed/mattress; offloading boots for heels; more frequent repositioning
≤9	Very high risk	All above + low air loss or alternating pressure mattress; wound care consult; nutritional support

S — Skin assessment: Head-to-toe skin inspection at least every shift; every turn for high-risk patients. Document condition, color, turgor, any changes.

K — Keep turning: Reposition at minimum every 2 hours (in bed); every 30–60 minutes in chair. 30-degree lateral tilt (not full 90°) preferred — reduces pressure on trochanter. Use wedge cushions to maintain position.

I — Incontinence management: Keep skin clean and dry; barrier cream/ointment (zinc oxide, Vaseline) for moisture; brief changes promptly; moisture-wicking products; avoid using diapers that trap moisture against skin.

N — Nutrition and hydration: Adequate protein (1.2–1.5 g/kg/day), calories, vitamins C and zinc for wound healing; dietitian consult for high-risk; hydration goal; address malnutrition.

S — Support surface: Pressure redistribution mattress for at-risk patients; specialized offloading heel boots (heels are highest risk site); do NOT use donut-shaped cushions (increase pressure at edges); do NOT elevate HOB >30° for extended periods (shear force).

HEELS: Float heels completely off bed surface with foam wedge under calf; inspect at every turn; no rigid devices under heels; multi-layer foam dressings preventively.

5. Wound Care Principles

Stage	Wound Bed Goal	Typical Dressing Options
Stage 1	Protect, relieve pressure	Transparent film; thin foam dressing; barrier cream; NO dressing required to cover intact skin
Stage 2	Moist wound healing; protect base	Hydrocolloid; foam dressing; transparent film; hydrogel for dry wounds
Stage 3–4	Debridement if needed; fill dead space; moisture balance	Wet-to-moist saline gauze (not wet-to-dry — damages healing tissue); alginates for heavy exudate; foam; negative pressure wound therapy (wound VAC); collagen dressings; consult wound care RN/team
Unstageable with stable eschar	Protect; do NOT debride (unless infected)	Dry protective dressing; iodine-based if concerns about infection; no moisture-retentive dressings over stable eschar

Wet-to-dry dressings are OUTDATED: Removing dry gauze traumatizes healthy granulation tissue. Use wet-to-moist or moist wound healing approach instead. Wet-to-dry is acceptable ONLY for mechanical debridement of heavily necrotic tissue when other options are unavailable — not for routine dressing changes on healing wounds.

6. Documentation Requirements

NCLEX High-Yield: Pressure Injuries

Stage 1: intact skin, non-blanchable redness
Stage 2: partial thickness, shallow open wound or blister
Stage 3: subcutaneous fat visible; Stage 4: bone/tendon/muscle visible
Unstageable: cannot determine depth due to slough/eschar covering wound
DTPI: maroon/purple intact (or non-intact) skin from deep tissue damage
Braden scale: lower score = higher risk; ≤9 = very high risk
Reposition: minimum every 2 hours in bed; 30–60 min in chair
Heels: float completely off bed surface; highest PI risk site in many patients
HOB: keep ≤30° to reduce shear (exception: aspiration prevention takes priority at 30–45°)
Cannot downstage: healing Stage 4 stays documented as Stage 4 until fully healed
Stable heel eschar: leave intact unless infected (do NOT routinely debride)
Donut cushions: contraindicated — increase pressure at ring edges

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Pressure Injuries Nursing Guide 2026