What it means
Localized damage from staying in one position or from a medical device pressing on the skin. It is staged by depth: stage 1 is intact skin with redness that does not blanch; stage 2 is partial loss of the skin; stage 3 is full-thickness skin loss into the fat; stage 4 exposes muscle, tendon or bone. An unstageable injury has a base hidden by dead tissue, and a deep tissue injury is a purple or maroon area of damage under intact skin.
For the nurse
Use a risk tool such as the Braden ScaleBRAY-den skaylA scoring tool that rates a client's risk of developing a pressure injury.Full entry , check the skin over bony areas and under devices every shift, reposition clients who cannot move themselves (at least every 2 hours in bed), keep skin clean and dry, and support nutrition. Never massage a reddened bony area.
At a glance
| Spanish | lesión por presión |
|---|---|
| Also written | pressure injuries |
Related terms
ulcer
An open sore where the skin or the lining of an organ has broken down.
repositioning
Changing a client's body position on a regular schedule, or moving a device to a new place.
bony prominence
A place where a bone lies close under the skin with little fat or muscle over it, such as the heel or tailbone.
Braden Scale
A scoring tool that rates a client's risk of developing a pressure injury.