Prevention and nursing collaboration Pressure injuries

What is the nurse's primary goal in pressure injury prevention?

To maintain skin integrity and prevent tissue breakdown before it occurs.

Why is prevention of pressure injuries a top nursing priority?

Because most are preventable through proper assessment and care.

What is the first step in preventing pressure injuries?

Identify patients at risk using tools like the Braden Scale.

How often should risk assessments be completed?

On admission, every shift, and after any significant change in condition.

What is the most effective intervention to reduce pressure?

Frequent repositioning and pressure redistribution.

How often should immobile patients be repositioned?

At least every 2 hours or per facility protocol.

How can nurses reduce pressure while sitting?

Encourage weight shifting every 15-30 minutes and use pressure-redistributing cushions.

What are examples of pressure-redistributing surfaces?

Foam mattresses, gel cushions, low-air-loss beds, and alternating pressure devices.

What is offloading?

Relieving pressure from high-risk areas such as heels or sacrum.

How can heel pressure be prevented?

Float heels off the bed using pillows or heel protectors.

Why should the head of the bed be kept ≤30 degrees?

It minimizes shear forces on the sacrum and coccyx.

What is the importance of keeping the skin clean and dry?

It reduces moisture-associated skin damage (MASD) and bacterial growth.

What should be used for skin cleansing?

Mild, pH-balanced cleansers and warm (not hot) water.

Why should soap with fragrance be avoided?

It strips natural oils and increases dryness.

What type of barrier product helps prevent skin damage from moisture?

Zinc oxide, silicone-based creams, or petrolatum barriers.

What should nurses teach incontinent patients or caregivers?

Frequent cleansing, use of absorbent products, and application of moisture barriers.

Why should absorbent briefs be changed promptly?

Prolonged moisture increases friction and maceration risk.

What are early indicators of pressure injury formation?

Redness, warmth, firmness, or pain over bony prominences.

What is the nurse's response to early signs of skin redness?

Relieve pressure, assess blanching, and apply protective dressing if needed.

What is the importance of maintaining proper nutrition?

Adequate calories, protein, and vitamins promote skin resilience and healing.

What dietary nutrients are critical for tissue repair?

Protein, vitamin C, zinc, and adequate hydration.

Why should hydration be emphasized in prevention?

Fluids maintain tissue elasticity and improve perfusion.

What lab values help assess nutrition for skin health?

Albumin (3.5-5.0 g/dL) and prealbumin (15-36 mg/dL).

Why should wrinkles and creases be smoothed from linens?

They create localized pressure points on the skin.

What should be avoided during patient repositioning?

Dragging or sliding the patient, which causes friction and shear.

What devices help reduce friction and shear?

Draw sheets, lift devices, and mechanical lifts.

Why should restraints be avoided when possible?

They increase immobility and risk of pressure injury beneath straps.

How can pain control aid prevention?

Pain-free patients move more frequently and reposition themselves.

What should be done for medical device-related pressure injuries (MDRPI)?

Assess under and around devices daily and pad or reposition as needed.

What devices commonly cause pressure injuries?

Oxygen tubing, masks, catheters, splints, and cervical collars.

How can nurses prevent device-related injuries?

Reposition or loosen devices regularly and apply foam or silicone padding.

What interdisciplinary team members help prevent pressure injuries?

Nurses, dietitians, physical and occupational therapists, wound care specialists, and physicians.

What is the role of the dietitian in prevention?

Assess nutritional needs and create high-protein, nutrient-rich plans.

What is the role of the physical therapist?

Improve mobility and teach pressure-relief exercises.

What is the role of the wound care nurse or specialist?

Provide advanced assessment, dressing recommendations, and education.

Why is collaboration with nursing assistants critical?

They perform routine repositioning, hygiene, and early skin assessments.

What should be documented in the care plan for prevention?

Repositioning schedule, skin condition, nutrition interventions, and patient education.

How can patient and family education support prevention?

Teaching the importance of movement, hydration, and early reporting of redness or pain.

Why is early detection vital in prevention?

It allows prompt intervention before irreversible tissue damage occurs.

What is the nurse's best tool in pressure injury prevention?

Vigilant assessment, documentation, and consistent repositioning.