[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Nursing](https://durgical.com/en/nursing/) › [Patient safety](https://durgical.com/en/nursing/areas/safety/) › Preventing pressure injuries: risk scales, repositioning and skin care # Preventing pressure injuries: risk scales, repositioning and skin care - Safe practice Patients at risk are identified, pressure is relieved by repositioning, and the skin is protected from moisture, friction and shear. Updated Nov 5, 2026 ## Key points - Assess risk on admission, then daily and whenever the patient's condition worsens, with a standardised scale and your clinical judgement. - Braden Scale: six areas: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. - Reposition on a schedule set by risk and protocol, often every 1 to 2 hours: two hours of uninterrupted pressure can be enough to cause damage. - Inspect the skin head to toe, including areas under devices (tubes, masks, splints). - Keep the heels off the mattress and use pressure-redistributing surfaces for patients at risk. ## What it is A pressure injury is localised damage to the skin and the tissue beneath it, usually over a bony prominence, and also where tubes and other devices stay in contact with the skin. It is caused by intense or prolonged pressure, alone or combined with friction and shear, which leaves the tissue without blood supply. The MinSalud technical guide counts its prevention among the safe care practices and notes that as little as two hours of uninterrupted pressure can cause damage. Prevention combines risk assessment with a standardised scale, such as the Braden or Norton scale, plus clinical judgement; head-to-toe skin inspection; regular repositioning; support surfaces; moisture control; and adequate nutrition. ## What it requires - Immobility or reduced mobility. - Impaired sensation or consciousness. - Moisture, for example from incontinence. - Poor nutrition or poor intake. - Older age, diabetes or obesity. - Medical devices in prolonged contact with the skin, such as tubes, masks and splints. ## Components - Sensory perception: ability to feel the discomfort of pressure and respond to it. - Moisture: how long the skin is exposed to moisture. - Activity: level of physical activity, from bed-bound to walking. - Mobility: ability to change position on one's own. - Nutrition: whether usual intake is adequate. - Friction and shear: how much help is needed to move and whether the patient slides in bed or chair. ## How it is applied (and why) - Assess risk with the institutional scale on admission and then daily: the risk sets how many measures the patient needs. - Inspect the skin head to toe in good light, on admission and at least daily: redness that does not blanch is the first sign. - Reposition the patient on a schedule, often every 1 to 2 hours: prolonged pressure leaves the tissue without blood. - Use pillows to lift pressure points off the bed and keep the heels elevated or protected: the heels are among the most frequent sites. - Move the patient up in bed with a draw sheet and at least two people, not by dragging: dragging causes friction and shear. - Use a special pressure-redistributing mattress or surface according to risk, in addition to repositioning: it helps spread the weight. - Clean the skin as soon as it is soiled and apply a protective barrier: moisture weakens the skin and makes injury easier. - Check the skin under tubes, oxygen tubing, masks and splints, and make sure tubes are well positioned: devices cause pressure injuries too. - Report low intake so nutrition can be assessed: protein and calories help keep the skin healthy and support healing. ## In nursing practice - At-risk areas change with position: sacrum, heels and occiput when supine; trochanters, shoulders, ears and malleoli when side-lying; ischia and coccyx when sitting. - Most pressure injuries are preventable: the MinSalud package cites an estimate of 95% from a Spanish expert group. - MinSalud asks that the scale be combined with clinical judgement; the scale alone is not enough. - A pressure injury that develops during hospital care is an adverse event and is reported. ## Common mistakes - Letting the patient slide down in bed or in the chair: sliding creates shear. - Dragging the patient across the sheet when moving them. - Skipping the daily head-to-toe skin inspection. - Forgetting to check the skin under medical devices. - Using the scale only on admission and never reassessing. ## Test yourself Think of the answer, then tap the question to see it. ## What are the six areas assessed by the Braden Scale? Sensory perception, moisture, activity, mobility, nutrition, and friction and shear. ## How often is a bed-bound patient at risk repositioned? On a schedule set by risk and the institutional protocol, often every 1 to 2 hours; two hours of uninterrupted pressure can already cause damage. ## Why should a patient not be dragged across the sheet when moved? Because dragging causes friction and shear, which damage the skin; the patient is lifted with a draw sheet and enough helpers. ## Besides bony prominences, where else must the skin be checked? Under medical devices such as tubes, oxygen tubing, masks and splints; oxygen tubing over the ears is one of the most common causes. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/nursing/preventing-pressure-injuries-risk-scales-repositioning-and-skin-care/) ## Connections ## Related 3 - [Pressure injury staging](https://durgical.com/en/nursing/pressure-injury-staging/) - [Patient positions: Fowler, supine, lateral, prone and others](https://durgical.com/en/nursing/patient-positions-fowler-supine-lateral-prone-and-others/) - [Patient safety in Colombia: the policy and its instructional packages](https://durgical.com/en/nursing/patient-safety-in-colombia-the-policy-and-its-instructional-packages/) [← All of nursing](https://durgical.com/en/nursing/) Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order. Sources: [Nursing Fundamentals, 10.5 Braden Scale](https://med.libretexts.org/Bookshelves/Nursing/Nursing_Fundamentals_(OpenRN)/10%3A_Integumentary/10.05%3A_Braden_Scale) (Open RN, Wisconsin Technical College System (CC BY 4.0), LibreTexts edition, 2021); [Guía técnica Buenas prácticas para la seguridad del paciente en la atención en salud, versión 1](https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/CA/guia-buenas-practicas-seguridad-paciente2010.pdf) (Ministerio de la Protección Social (MinSalud), Colombia, 2010); [Paquetes instruccionales: Prevención úlceras por presión, versión 2.0 (guía técnica Buenas prácticas para la seguridad del paciente en la atención en salud)](https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/CA/prevenir-ulceras-por-presion.pdf) (Ministerio de Salud y Protección Social (MinSalud), Colombia, 2015); [Prevalence and Analysis of Medical Device-Related Pressure Injuries: Results from the International Pressure Ulcer Prevalence Survey](https://pmc.ncbi.nlm.nih.gov/articles/PMC5991189/) (Advances in Skin & Wound Care (PubMed Central), 2018). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/nursing/preventing-pressure-injuries-risk-scales-repositioning-and-skin-care/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/nursing/preventing-pressure-injuries-risk-scales-repositioning-and-skin-care/