A pressure injury is damage to skin and deeper tissue from long-lasting pressure, often with shear, usually over a bony area such as the sacrum or heels. It is common in patients who are immobile, older or critically ill, and most can be prevented with good nursing care.
Key symptoms
- Pain or tenderness over a bony area
- Red or purple skin that does not fade
- Open wound, drainage or odor
- Risk factors: immobility, incontinence, poor nutrition, reduced sensation
What you find on exam
- Stage 1: intact skin with redness that does not blanch
- Stage 2: partial-thickness loss with exposed dermis, or an intact blister
- Stage 3: full-thickness loss with visible fat; stage 4: exposed bone, tendon or muscle
- Unstageable (covered by slough or eschar) and deep tissue injury (purple or maroon area)
- Measure size, depth, tunneling, drainage and the skin around the wound
Tests
- Braden scale risk score on admission and at regular intervals
- Nutrition assessment: weight, food intake and diet history
- Tissue biopsy culture if infection is suspected, not a surface swab
- X-ray, MRI or bone biopsy if osteomyelitis is suspected
Treatment basics
- Reposition at least every 2 hours and use a pressure-redistributing mattress
- Offload the heels; limit head-of-bed elevation to reduce shear
- Wound care: clean, keep moist with dressings, remove dead tissue (debridement)
- Manage moisture and incontinence; improve nutrition and protein intake
- Antibiotics for infection; surgery for deep stage 4 wounds
Red flags
- Fever, spreading redness or foul drainage
- Bone seen or felt at the wound base (osteomyelitis)
- Fast worsening despite care, or signs of sepsis
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Sources: NCSBN 2026 NCLEX-RN Test Plan; NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations. Written by Making Synapses. Making Synapses is not affiliated with these organizations.