Updated July 2026 · 9 min read
Part of the ICU Emergencies Hub — browse every related guide in one place.
The sickest, least mobile patients in the hospital live in your unit — sedated, on pressors, tethered to a dozen devices, and often too unstable to turn easily. That is the exact recipe for a pressure injury, and the exact reason ICU nurses own this problem more than anyone. The good news: the overwhelming majority of these injuries are preventable, and the prevention comes down to a handful of things done relentlessly.
Staging describes the depth of tissue loss using the National Pressure Injury Advisory Panel definitions. You stage by the deepest tissue you can actually see or feel.
| Stage | What you see |
|---|---|
| Stage 1 | Intact skin with non-blanchable erythema. Press and the redness stays. In darker skin tones it may not look red at all — look for a change in color, temperature, or firmness compared to surrounding skin. |
| Stage 2 | Partial-thickness loss of skin with exposed dermis. A shallow, pink-red, moist open ulcer, or an intact/ruptured serum-filled blister. No slough, no visible fat. |
| Stage 3 | Full-thickness skin loss. Subcutaneous fat is visible; slough or eschar may be present but does not obscure the base. May have undermining or tunneling. No bone, tendon, or muscle showing. |
| Stage 4 | Full-thickness loss with exposed or directly palpable bone, tendon, muscle, or cartilage. Undermining and tunneling are common. |
| Unstageable | Full-thickness loss where the base is obscured by slough or eschar. You cannot judge depth until enough is removed — so it cannot be numbered yet. |
| Deep tissue pressure injury (DTPI) | Intact or non-intact skin with persistent, non-blanchable deep red, maroon, or purple discoloration, or a blood-filled blister. Damage started at the bone–muscle interface from pressure and shear and may evolve rapidly. |
The Braden Scale scores six factors, each rated 1–4 (friction/shear is 1–3). A lower total means higher risk; a score of 18 or below generally flags a patient who needs a prevention plan, and most ICU patients score well under that.
| Braden subscale | What it captures |
|---|---|
| Sensory perception | Can the patient feel and respond to discomfort? Sedation and neuropathy erase this. |
| Moisture | Skin exposure to sweat, urine, stool, wound drainage. |
| Activity | Degree of physical activity (most ICU patients are bedfast). |
| Mobility | Ability to change and control body position. |
| Nutrition | Usual food/protein intake — often poor or NPO in critical illness. |
| Friction & shear | Sliding against sheets during repositioning and boosts. |
Use the subscales, not just the total. A patient with an acceptable total but a rock-bottom moisture or sensory score still needs targeted intervention on that specific driver.
Prevention is not one action; it is a bundle done consistently. The core elements:
| Intervention | Why it works |
|---|---|
| Reposition on a schedule (commonly q2h, individualized) | Interrupts sustained pressure over bony prominences before tissue ischemia sets in |
| Float the heels | The heel has almost no cushioning tissue; suspend it on a pillow or offloading boot so it bears no weight |
| Head of bed ≤ 30° when tolerated | Higher angles add shear at the sacrum as the patient slides down — shear is as damaging as pressure |
| Pressure-redistribution surface | A proper mattress or overlay spreads load; standard mattresses concentrate it |
| Skin inspection every shift | Catches Stage 1 and deep-tissue color changes while they are still reversible |
| Moisture management | Prompt incontinence care and a barrier cream keep macerated skin from breaking down |
| Nutrition and hydration | Adequate protein and calories are what the body rebuilds skin with; involve dietitian early |
| Device rounds | Rotate, pad, and reposition tubing, ETT ties, pulse-ox probes, and BP cuffs — devices cause a large share of ICU injuries |
Several critical-care realities stack the deck:
The most common sites remain the sacrum and heels, followed by the occiput, ears (from ETT ties and tubing), and anywhere a device presses.
Stage by the deepest tissue you can see, respect the categories that can't be numbered (unstageable, DTPI, mucosal, device-related), and never downgrade a healing wound. Then put your energy where it counts: the injury you prevent costs the patient nothing, and prevention is almost entirely nursing-driven — assess the risk, run the bundle every shift, and treat the skin assessment as seriously as any drip you titrate.
This article is general educational information for licensed clinicians and students, not medical advice or a substitute for your institution's protocols or a provider's orders. Always follow facility policy.
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