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Patient summary
The patient is illustrative. Mr. G., 84, is on day 2 after surgery for a hip fracture. He is drowsy from pain medication, has urinary incontinence, eats less than half of each meal and needs two staff members to move in bed. The skin over his sacrum is intact, but there is a patch of redness that fades when pressed.
Assessment
The Braden Scale predicts pressure injury risk with six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Totals range from 6 to 23, and lower scores mean higher risk (Bergstrom et al., 1987).
| Subscale | Mr. G.'s score |
|---|---|
| Sensory perception | 3 (slightly limited) |
| Moisture | 2 (very moist) |
| Activity | 1 (bedfast) |
| Mobility | 2 (very limited) |
| Nutrition | 2 (probably inadequate) |
| Friction and shear | 1 (problem) |
| Total | 11 (high risk) |
Redness that blanches is not a pressure injury. A Stage 1 pressure injury is intact skin with redness that does not blanch. The National Pressure Ulcer Advisory Panel's 2016 staging system uses the term injury instead of ulcer, Arabic numerals for stages, and separate categories for unstageable injuries, deep tissue pressure injuries and injuries caused by medical devices (Edsberg et al., 2016).
Nursing diagnosis
Risk for pressure injury, with risk factors of immobility, incontinence, poor nutritional intake, and friction and shear (Herdman et al., 2024).
Goal
Mr. G.'s skin will remain intact, with no Stage 1 or higher pressure injury, throughout his stay.
Interventions and rationales
| Intervention | Rationale |
|---|---|
| Reposition at least every 2 to 4 hours on a pressure-redistributing mattress, using a 30-degree tilt and a turning schedule posted at the bedside | In the TURN trial in 27 nursing homes, 942 residents at moderate or high Braden risk on high-density foam mattresses had similar, low pressure injury rates (2.0% overall) whether they were turned every 2, 3 or 4 hours, as long as repositioning was consistent and skin was checked (Bergstrom et al., 2013) |
| Float the heels off the bed with a pillow under the calves | Heels are a common site after hip surgery |
| Clean the skin promptly after each episode of incontinence and apply a barrier cream | Moisture weakens skin and increases friction damage |
| Use a lift sheet and two staff to move him; keep the head of the bed at 30 degrees or lower when possible | Reduces shear forces on the sacrum |
| Offer high-protein snacks and fluids, and request a dietitian referral | Poor nutrition slows tissue repair and raises risk |
| Inspect all bony prominences and under devices each shift, and repeat the Braden score daily | Early detection allows a change in plan before injury develops |
Evaluation
At discharge to rehabilitation, Mr. G.'s skin is intact, the sacral redness has resolved, his Braden score has risen to 15 as his mobility and intake improve, and his care plan goes with him.
References
Bergstrom, N., Braden, B. J., Laguzza, A., & Holman, V. (1987). The Braden Scale for predicting pressure sore risk. Nursing Research, 36(4), 205–210. https://doi.org/10.1097/00006199-198707000-00002
Bergstrom, N., Horn, S. D., Rapp, M. P., Stern, A., Barrett, R., & Watkiss, M. (2013). Turning for Ulcer ReductioN: A multisite randomized clinical trial in nursing homes. Journal of the American Geriatrics Society, 61(10), 1705–1713. https://doi.org/10.1111/jgs.12440
Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised National Pressure Ulcer Advisory Panel pressure injury staging system. Journal of Wound, Ostomy and Continence Nursing, 43(6), 585–597. https://doi.org/10.1097/WON.0000000000000281
Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2024). NANDA International nursing diagnoses: Definitions and classification, 2024–2026 (13th ed.). Thieme.
