Pressure Ulcers

Publication ID: 1646041022
Published on: August 2023
Major Revision: April 17, 2024


Pressure ulcers are defined as damage to the skin and underlying tissues caused by pressure, shear, excessive moisture, or friction. Severe pressure ulcers can cause pain and infection, contribute to longer hospital stays, and compromise the estimated recovery trajectory. Pressure ulcers impact 2.5 million patients in US hospitals each year, resulting in the deaths of approximately 60,000. Financial cost estimates in the US alone range from $9.1 to 11.6 billion annually. Yet despite the significant number of lives lost, studies have shown that only 9.7% of patients who were at risk for pressure ulcers received adequate preventive care. By implementing the evidence-based protocols outlined in this blueprint, healthcare organizations can significantly reduce injuries from pressure ulcers.
Frontline staff

This blueprint outlines the steps that frontline staff can follow to prevent pressure ulcers:


  1. Perform a risk and skin assessment within four hours of admission, including the time in the emergency department prior to admission. Use the organization’s standard assessment tool (e.g., Braden scale).
  2. Consider including a visual document/photo on each admission record for the total skin assessment.

Routine care:

  1. Every two hours, reposition patient.
  2. Reassess pressure ulcer risk and skin for all patients at least once daily (every 24 hours). Use tools to understand severity for different types of skin tones.
  3. Keep patient’s skin dry, moisturized, and clean.
  4. Minimize exposure of skin to moisture from sources such as perspiration, wound drainage, and excrement. If this is not possible, use absorbent underpads and ensure that skin is cleansed at the time of soiling using mild cleansing agents.
  5. Have supplies available at the bedside for each at-risk patient if they are incontinent.
  6. Ensure proper nutrition and hydration.
  7. Adapt a reposition treatment plan individualized for each patient according to risk.
  8. Encourage mobility to the extent the patient is capable.
    1. Use lift devices or draw sheets to move patients with limited mobility.
    2. Take caution to avoid dragging or pushing into the patient’s skin when moving.
  9. Use pillows under heels and bony prominences to redistribute pressure.
  10. Involve patients and family members in pressure ulcer prevention.
  11. Utilize wearable patient sensors if and when possible to prevent hospital-acquired pressure injuries.

If a pressure ulcer develops:

  1. Order a wound consult.
  2. Cleanse the ulcer with a nontoxic solution, such as normal saline, at every dressing change.
  3. Cleanse the surrounding area.
  4. Classify the pressure ulcer using tools such as the National Pressure Ulcer Staging System (US) or the International NPUAP/EPUAP Pressure Ulcer Classification System.
  5. For every dressing change, evaluate the need for a change in treatment.
  6. Document all results of the wound assessment, including location, category/stage, size, tissue type, color(s), wound edges, condition of skin around the wound, and odor.
  7. Remain vigilant for pressure ulcer-related infection.
  8. Consider possible alleviations, including physical therapy, muscle relaxants, pressure redistributing devices, negative pressure wound therapy, debridement, and dressings, such as alginate dressings, hydrocolloid dressings, foams, and/or gels.


  1. Document risk and skin assessment for the receiving facility.
  2. Coordinate supplies for pressure ulcer prevention and treatment for at-risk patients.
  3. Spend time with the patient and family members in the days leading up to discharge to ensure everyone understands the importance of pressure ulcer prevention, daily steps to prevent pressure ulcers, and the patient-specific risk factors.
Unit Managers

This guide outlines the steps that managers can follow to prevent pressure ulcers:

Use this checklist as a guide to determine whether current evidence-based guidelines are being followed in your organization:

Provide ongoing education.

  1. Provide pressure ulcer-specific ongoing education and include pressure ulcer education in other related education (e.g., education around ventilator management, mobility, medical device use, etc.).
  2. Ensure all tools, images, and educational materials include pressure ulcer presentation across multiple skin tones.
  3. Include actionable steps that patients and family members can take to prevent pressure ulcers in patient-facing educational materials.

Engage those on the frontline in quality-improvement initiatives.

  1. Identify a pressure ulcer champion to visibly lead prevention efforts and engage frontline staff.
  2. Identify and publicize what all roles can do to prevent pressure ulcers.
  3. Ensure that pressure ulcer prophylaxis and treatment protocols are embedded into clinical workflows, whether electronic or paper.
  4. Ensure there are enough staff to effectively manage necessary preventive care.
  5. Evaluate the clinical workflow to embed pressure ulcer surveillance into pre-existing processes to optimize efficiency. Bundle pressure ulcer prevention with other related activities.
  6. Encourage documentation of both assessment findings and prevention strategies employed.

Standardize processes and measure trends.

  1. Make sure patients are repositioned every two hours.
  2. Set clear, unambiguous aim statements.
  3. Standardize risk and skin assessment tools across the system to optimize data integrity.
  4. Measure and report pressure ulcer process and outcome metrics monthly. Note trends in areas with low compliance and high pressure ulcer incidence. Routinely reassess outcomes.
  5. Debrief on a regular basis to solicit team feedback about barriers to sustained compliance. Adjust the plan quickly and nimbly as needed.
  6. Ensure that leaders have a simple process to oversee pressure ulcer improvement work while also considering how it aligns with other initiatives across the organization.
  7. Consider incorporating pressure sensors that will alert the caregiver if the patient needs to be moved.


  1. Pressure ulcer assessment upon admission
  2. Pressure ulcer reassessment during routine care
  3. Diet and fluid intake assessment and how this is linked with pressure ulcer assessments in the EHR or other documentation
  4. Documentation of pressure ulcer assessment
  5. Use of pressure redistribution devices
  6. Measures taken when a patient is at risk for pressure ulcers and when these measures are implemented (e.g., immediately or upon worsening)
  7. Mobility decision-making discussions
  8. Discharge planning
  9. Patient and family member education


  1. It is difficult to assess which patients arrived with a pressure ulcer.
  2. Clinicians may prioritize patient comfort over skin assessment.
  3. Skin assessment is competing with other higher priorities.
  4. There’s differential interpretation of the skin assessment among clinicians.
  5. The assessment is not conducted multiple times while the patient is in the hospital.
  6. Different scales are used across the organization.
  7. Policies are not reinforced by workflows/task lists.
  8. There’s no prompt for the nurse to document the assessment.
  9. Assessment documentation may not be pulled into the patient chart for ongoing comparison with other assessments.
  10. The documentation data integrity is compromised between units/facilities.
  11. The standardized rounding is not consistent or tailored to the patient’s needs (e.g., if the patient is incontinent, hourly may not be enough).
  12. Workers may not know what interventions are available to prevent pressure ulcers.
  13. In the assessment of pressure ulcers specifically, there’s no assessment of factors that may contribute to pressure ulcers (e.g., mobility, nutrition, medications, restraints, etc.).
  14. Staff are rushed during ongoing assessment and face competing priorities.
  15. Pressure ulcers may not be detected as readily for those with darker skin tones.
  16. Patient is transported or discharged before the wound care nurse can see the patient.
  17. There is a shortage of wound care nurses.
  18. The receiving facility does not have data from previous risk assessments.
  19. Wound interventions are not communicated to the receiving facility.
  20. Pressure ulcer prevention is not incorporated into patient education at discharge.
  21. Only previous wounds are documented in the EHR. If the patient is at risk, but did not have a previous wound, this is often not documented.
  22. Case managers may not know to order any equipment/services for pressure ulcer prevention if the risk or previous wound is not documented.
  23. Patients and family members interpret mobility status differently than the clinician. Equipment to facilitate early mobility is not readily accessible.
  24. Clinicians do not acknowledge the patient’s fear of falling when working to implement early mobility interventions.
  25. The responsibility of early mobility management is placed on one discipline.
  26. It is assumed that the initial mobility assessment is sufficient throughout care despite changes.
  27. Fall risks are not recognized.
  28. Mobility processes are not audited or reviewed routinely.
  29. The family does not know their role in continuing mobility in the home setting.
  30. Patients do not have help in picking up and transporting durable medical equipment.
  31. There’s no follow-up post-hospitalization.
  32. Processes for accountability are lacking.
Hospital Executives

This guide outlines the steps that executives can follow to prevent pressure ulcers: 

The Problem

Pressure ulcers impact 2.5 million patients in the US each year and are prevalent in 18.1% of patients in European countries. It has been shown that only 9.7% of patients who were at risk for pressure ulcers received adequate preventive care.

The Cost

In the US alone, pressure ulcers cost between $9.1 and $11.6 billion annually. Per patient, this cost can range from $20,900 to $151,700 per pressure ulcer. It is estimated that hospital-acquired pressure ulcers add $43,180 to hospital stay costs. Still, despite these significant costs, approximately 60,000 patients die as a direct result of pressure ulcers annually.

The Solution

Many healthcare organizations have successfully reduced injuries from pressure ulcers. The Actionable Evidence-Based Practices checklists  outline steps that frontline staff, managers, patients, and healthcare executives should take to successfully prevent pressure ulcers.

What We Know About Pressure Ulcers

Pressure ulcers are defined as damage to the skin and underlying tissues caused by pressure, shear, excessive moisture, or friction. Pressure ulcers impact 3%–14% of inpatients and up to 70% of older hospitalized adults. Severe pressure ulcers can cause pain and infection, contribute to longer hospital stays, and compromise the estimated recovery trajectory.

Populations at Risk

There have been more than 100 risk factors for pressure ulcers identified in the literature, ranging from chronic health conditions to age and health habits. While it is important to acknowledge the risk factors of each individual, pressure ulcer precautions should be embedded in the clinical routine workflow for all patients. Pressure ulcers are often first identified by sight. It is important to recognize that pressure ulcers may present differently on individuals depending on skin tone. Do not discount a potential pressure ulcer sighting because it doesn’t look exactly as it looked on another patient. Investigate further if a pressure ulcer is suspected. Immobility and limited activity are common causes of pressure ulcers, emphasizing the importance of early mobility management for inpatients.

Patient & Families

The following guide outlines the steps that patients and patient families can follow to prevent pressure ulcers: 

Pressure ulcers are damage to the skin and underlying tissues caused by pressure, shear, excessive moisture, or friction, often associated with limited mobility, such as when lying in a hospital bed, for extended periods of time. Severe pressure ulcers can cause pain and infection, contribute to longer hospital stays, and delay recovery.

As a patient and/or family member, you can help prevent pressure ulcers by:

  1. Asking for the healthcare provider’s overview of the patient’s specific risk factors
  2. Making sure you are, as a patient, or your loved one is repositioned every two hours
  3. Ensuring the patient’s board is updated with their pressure ulcer risk information
  4. Asking for a description of pressure ulcers and what indications to watch out for and when to call for help
  5. Asking how family members can help maintain the patient’s daily nutrition, fluid intake, and mobility plans
  6. Understanding the importance of keeping the patient’s skin dry
  7. Collaborating on a “schedule” that the patient should follow daily to prevent pressure ulcers in the hospital and post-discharge
  8. Getting supplies for the patient to prevent pressure ulcers post-discharge, particularly if there is incontinence
  9. Asking for relevant information that patients and family members should get from providers during their upcoming healthcare visits
  10. Asking for clarification on the patient’s wound care plan and appointments post-discharge as applicable
  11. Working to understand any barriers the patient may have in pressure ulcer prevention and discussing strategies to overcome those barriers, taking the patient’s individual circumstance into account

AHRQ. Preventing Pressure Ulcers in Hospitals 

Center for Medicare & Medicaid Services. QRP POCKET GUIDE – Pressure Ulcer/Injury Coding Stages

Hayashi, Y., et al. Drug-induced Pressure Ulcers in a Middle-aged Patient with Early-stage Parkinson’s Disease. (2018)

Mayo Clinic. Bedsores (pressure ulcers)

Osuagwu B, et al. A pressure monitoring approach for pressure ulcer prevention. (2023)

Phoong K, et al. Advancing pressure ulcer prevention: evaluating the impact of patient and lay carer education. (2023)

Visconti A, et al. Pressure Injuries: Prevention, Evaluation, and Management. (2023)