Updated July 2026 · 9 min read
Part of the ICU Emergencies Hub — browse every related guide in one place.
A hospital-acquired pressure injury is one of the few ICU complications that is almost entirely nurse-preventable — and it is a quality metric that regulators, insurers, and your unit watch closely. The critically ill patient is the perfect storm for skin breakdown: immobile, sedated, on pressors that starve peripheral tissue, often incontinent and edematous. Prevention is not a single task; it is a small, relentless bundle that a nurse owns from admission.
The Braden Scale scores six factors that drive breakdown. Each is rated 1–4 (except friction/shear, 1–3), and the totals range from 6 (highest risk) to 23 (lowest):
| Subscale | What it measures |
|---|---|
| Sensory perception | Ability to feel and respond to discomfort (sedated/comatose = low) |
| Moisture | Skin exposure to sweat, urine, stool, drainage |
| Activity | Degree of physical activity (bedfast = low) |
| Mobility | Ability to change and control position |
| Nutrition | Usual food/protein intake |
| Friction & shear | Sliding down in bed, needing help to move |
A typical intubated, sedated ICU patient scores low on nearly every subscale, which is why most critical-care patients screen as high risk regardless of the exact cutoff. Treat the Braden score as a prompt to intensify the bundle, not as permission to relax when the number looks borderline — clinical judgment overrides the score. Rescore with any change in condition.
Accurate staging drives treatment and documentation. The current framework:
| Stage | Appearance |
|---|---|
| Stage 1 | Intact skin, non-blanchable redness (in darker skin, a change in color/temperature/firmness vs surrounding tissue) |
| Stage 2 | Partial-thickness loss — shallow open ulcer or intact/ruptured blister, pink-red wound bed, no slough |
| Stage 3 | Full-thickness loss — fat visible, possible slough, may have undermining/tunneling |
| Stage 4 | Full-thickness loss with exposed muscle, tendon, or bone |
| Deep tissue injury (DTI) | Intact or blistered skin over a persistent, non-blanchable deep purple/maroon area — a bruise that is really a deep wound evolving |
| Unstageable | Full-thickness loss where slough or eschar hides the depth — cannot be staged until the base is visible |
Prevention is a handful of interventions done consistently:
Reposition on a schedule. Turn and offload pressure regularly (commonly every 2 hours, individualized to the patient and surface), using a 30-degree lateral tilt rather than direct side-lying on the trochanter. Even small, frequent shifts of weight help. In a patient too unstable to fully turn, micro-repositioning and offloading still matter.
Float the heels. The heel has almost no cushioning tissue and is the second most common ICU pressure site. Lift heels off the bed entirely with a pillow under the calves or a heel-suspension boot — do not just pad them in place.
Manage moisture. Incontinence-associated dermatitis softens skin and multiplies breakdown risk. Clean promptly, use a barrier cream, and consider a fecal or urinary management system for high-output stool. Keep linens dry and wrinkle-free.
Reduce friction and shear. Use draw sheets and lifts to move rather than drag, keep the head of bed at the lowest safe angle (elevation slides the sacrum), and consider prophylactic sacral/heel foam dressings in high-risk patients.
Check under every device. Endotracheal tube ties, NG tubes, cervical collars, BiPAP masks, SpO2 probes, and IV tubing all cause device-related pressure injuries. Rotate probe sites, cushion collars, and inspect the skin beneath anything hard on a schedule.
Pressors deserve their own mention: norepinephrine and vasopressin shunt blood away from skin, so a patient on high-dose vasopressors can develop breakdown despite good turning — watch them closely and lower the turning threshold. Prone-positioned ARDS patients need a completely different pressure map (face, chest, knees, genitals) and dedicated padding. And the edematous, third-spacing patient has fragile, taut skin that tears easily — handle gently.
Score every ICU patient with the Braden Scale, assume most are high risk, and run the bundle without waiting for redness to appear: reposition on schedule, float the heels, keep skin clean and dry, reduce shear, feed the patient, and inspect under every device. Document skin thoroughly on admission so a wound that came with the patient is never miscounted as one you caused. Pressure injuries are largely preventable, and preventing them is one of the clearest ways nursing vigilance shows up in outcomes.
Related: VTE / DVT prophylaxis · ICU delirium & the CAM-ICU · Train-of-four monitoring
Educational content for licensed clinicians. Always follow your facility's protocol and provider orders. Not medical advice.
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