Editing Fundamentals of Nursing (section)

=== Pressure injury prevention ===

Risk is assessed with the Braden Scale, which scores six subscales (sensory perception, moisture, activity, mobility, nutrition, and friction and shear). Lower scores mean higher risk, and a score of 18 or less generally indicates risk in adults.

Staging in brief:
* '''Stage 1:''' intact skin with nonblanchable erythema.
* '''Stage 2:''' partial thickness loss of dermis, shallow open ulcer or intact or ruptured serum filled blister. No slough or eschar.
* '''Stage 3:''' full thickness loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.
* '''Stage 4:''' full thickness loss with exposed bone, tendon, or muscle.
* '''Unstageable:''' the base is obscured by slough or eschar, so depth cannot be determined.
* '''Deep tissue pressure injury:''' persistent nonblanchable deep red, maroon, or purple discoloration, or a blood filled blister, over intact or nonintact skin.

Prevention: repositioning schedule, pressure redistribution surfaces, heel offloading with pillows under the calves so the heels float, keeping skin clean and dry, moisture barrier products, adequate protein and calorie intake, and avoiding massage over bony prominences or reddened areas. Do not use donut or ring cushions, which concentrate pressure at the rim.