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Pressure Injury Prevention Guide

Braden Scale, SSKIN Bundle & Wound Management for GCC Nurses  |  Based on NPUAP/EPUAP/PPPIA 2019

ℹ Classification based on the NPUAP/EPUAP/PPPIA 2019 Prevention and Treatment of Pressure Ulcers/Injuries Clinical Practice Guideline. "Pressure Ulcer" terminology updated to "Pressure Injury" in 2016.

Pressure Injury Staging System

STAGE 1
Stage 1 — Non-blanchable Erythema
Intact skin with a localized area of non-blanchable erythema. May appear differently in darkly pigmented skin (warmth, firmness, or pain). Skin is intact.
Key test: blanching with fingertip pressure — Stage 1 does NOT blanch.
STAGE 2
Stage 2 — Partial Thickness Skin Loss
Partial thickness loss of skin with exposed dermis. Wound bed is viable, pink or red, moist. May present as intact or ruptured serum-filled blister. No slough or bruising.
Shallow open ulcer or blister. Do not use for moisture-associated skin damage (MASD).
STAGE 3
Stage 3 — Full Thickness Skin Loss
Full thickness loss of skin. Subcutaneous fat and granulation tissue may be visible. Slough or eschar may be present. Undermining and tunnelling may occur. No fascia, muscle, tendon, ligament, cartilage, or bone exposed.
Depth varies by location — nasal bridge Stage 3 may be shallow; areas with significant adiposity may be very deep.
STAGE 4
Stage 4 — Full Thickness Tissue Loss
Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. Slough or eschar may be present. Undermining/tunnelling often present.
Risk of osteomyelitis. Mandatory incident report in JCI hospitals. Potential never event.
UNSTAGEABLE
Unstageable — Obscured Full Thickness
Full thickness skin and tissue loss where actual depth is obscured by slough (yellow, grey, green, brown) or eschar (tan, brown, black). True depth — and therefore true stage — cannot be determined until sufficient slough/eschar is removed.
Exception: stable dry eschar on heels — do NOT debride unless infection signs (erythema, fluctuance, odour).
DTPI
Deep Tissue Pressure Injury (DTPI)
Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discolouration, or epidermal separation revealing a dark wound bed or blood-filled blister. Boggy or firm texture. Pain and temperature change may precede skin colour changes.
Often evolves rapidly to expose actual extent of tissue injury. High-risk indicator requiring immediate intervention.
MDRPI
Medical Device Related Pressure Injury (MDRPI)
Results from use of a medical device. The resulting pressure injury generally conforms to the pattern or shape of the device. These injuries should be staged using the staging system above.
GCC ICU common causes: NGT (nasal ala), O2 mask (nasal bridge/cheeks), ET tube (lips/corners of mouth), cervical collar, compression stockings, pulse oximeter probes.
MUCOSAL
Mucosal Membrane Pressure Injury
Found on mucous membranes with a history of use of a medical device. Due to the anatomy of the tissue, these injuries cannot be staged using the staging system.
Common sites: oral mucosa (oral airways, ET tubes), nasal mucosa (NGT, nasal prongs), urethral meatus (urinary catheters).

Common Pressure Injury Sites — GCC ICU Context

High-Risk Anatomical Locations
Supine / Sedated Patients
Sacrum / Coccyx Heels (bilateral) Occiput Shoulder blades Elbows Spine / Vertebrae
Device-Related Sites (GCC ICU)
Nasal bridge (NIV/BiPAP mask) Nasal ala (NGT) Lips/mouth corners (ETT) Ear lobes (O2 tubing) Forehead (ET tie) Dorsum of foot (splints)
⚠ In dark skin tones, erythema may be difficult to visualise. Assess skin temperature (warmth = inflammation), firmness, oedema, and patient-reported pain. Use a standardised skin tone scale (e.g., ITA scale or Fitzpatrick Type IV–VI adapted protocols).
ℹ The Braden Scale was developed by Barbara Braden & Nancy Bergstrom (1987). Max score = 23. A lower score indicates higher risk. Reassess every shift in ICU, daily on general wards, and on any clinical change.
Braden Scale Calculator

1. Sensory Perception  Max 4

Ability to respond meaningfully to pressure-related discomfort

1
Completely Limited
No response to pain; LOC or paralysis
2
Very Limited
Responds only to pain; can't communicate discomfort
3
Slightly Limited
Responds to verbal commands; deficit in 1–2 extremities
4
No Impairment
Responds to verbal; no sensory deficit

2. Moisture  Max 4

Degree to which skin is exposed to moisture

1
Constantly Moist
Skin almost always wet (sweat, urine)
2
Often Moist
Linen change at least once per shift
3
Occasionally Moist
Extra linen change ~once daily
4
Rarely Moist
Skin usually dry; routine linen change

3. Activity  Max 4

Degree of physical activity

1
Bedfast
Confined to bed
2
Chairfast
Ability to walk limited/non-existent; requires chair/wheelchair
3
Walks Occasionally
Short distances with or without assistance
4
Walks Frequently
Outside room at least twice/day; moves in room every 2 hrs

4. Mobility  Max 4

Ability to change and control body position

1
Completely Immobile
Cannot make even slight positional changes without assistance
2
Very Limited
Occasional slight position changes; unable to independently
3
Slightly Limited
Frequent though slight changes in body/extremity position
4
No Limitations
Makes major and frequent position changes without assistance

5. Nutrition  Max 4

Usual food intake pattern

1
Very Poor
<1/3 of meals; rarely eats >2 protein servings; NPO >5 days
2
Probably Inadequate
Rarely eats full meals; ~3 protein servings; supplements occasionally
3
Adequate
Eats >half meals; 4 protein servings; tube feed/TPN meeting most needs
4
Excellent
Every meal; never refuses food; >4 protein servings; no supplements needed

6. Friction & Shear  Max 3

Note: this subscale is scored 1–3, not 1–4

1
Problem
Requires moderate–maximum assistance to move; frequently slides down
2
Potential Problem
Moves feebly or requires minimum assistance; some sliding occurs
3
No Apparent Problem
Moves independently with sufficient muscle strength; maintains position
Total Braden Score
—
Select all 6 subscales to calculate
≤9 Very High Risk 10–12 High Risk 13–14 Moderate Risk 15–18 Mild Risk 19–23 No Risk
ℹ The SSKIN Bundle is an evidence-based care bundle widely adopted across GCC hospitals and aligned with NHS Improvement and JCI pressure injury prevention requirements.

SSKIN Prevention Bundle

S

Skin Inspection — Every Shift

Head-to-toe skin inspection every shift focusing on all bony prominences and areas under medical devices.

S

Surface — Pressure-Redistributing Support

Select and maintain appropriate support surface based on Braden score and patient condition.

K

Keep Moving — Repositioning Schedule

Regular repositioning to redistribute pressure. Standard: 2-hourly. Dynamic mattress: 4-hourly permitted if skin intact and patient tolerates.

I

Incontinence & Moisture Management

Moisture-associated skin damage (MASD) doubles the risk of pressure injury. Manage moisture proactively.

N

Nutrition & Hydration

Malnutrition is an independent risk factor for pressure injury development and impaired healing.

Repositioning Clock

Repositioning Log (2-hour interval tracker)

Status: No log yet — click to record first repositioning

Heel Offloading Protocol

Heel Care — Highest Priority After Sacrum

Medical Device Skin Care

MDRPI Prevention Protocol
Daily Inspection
Remove device at least once daily (if clinically safe). Inspect underlying skin for erythema, excoriation, or open areas.
Reposition / Rotate
Rotate NGT to opposite naris every 24–48 hrs. Reposition O2 mask straps. Move oximeter probe to alternate finger every 4 hrs.
Padding
Apply foam padding or hydrocolloid dressing under device at bony prominences (nasal bridge under NIV mask, nasal ala under NGT).
Right Size / Fit
Ensure correct device sizing. Oedema changes fit — reassess ETT lip positioning post-intubation and daily in oedematous patients.

Dressing Selection Guide by Stage

Stage / Type Wound Characteristics Recommended Dressings Key Points
Stage 1 Intact skin, non-blanchable erythema. No open wound. Moisture barrier cream. Thin film dressing or thin foam if friction risk. No dressing required routinely. Protect from friction. Relieve pressure IMMEDIATELY.
Stage 2 Shallow open wound or blister. Low–moderate exudate. No necrosis. Low exudate: Hydrocolloid (change every 3–7 days)
Moderate exudate: Foam dressing
Blister intact: Film dressing or thin foam		 Maintain moist wound environment. Do not unroof blisters unless infected. Change only when saturated or leaking.
Stage 3 Full thickness, fat visible. May have slough/granulation. Moderate–heavy exudate. Alginate or hydrofibre cavity filler + foam border dressing. Debride if necrotic (autolytic: hydrogel; sharp: TVN/surgeon). Measure depth; pack loosely (do not overpack). Refer to tissue viability nurse. Reassess weekly minimum.
Stage 4 Bone/tendon/muscle visible. Heavy exudate. Tunnelling/undermining likely. Irrigate with saline. Alginate ribbon or hydrofibre for cavities/tunnels. Foam with border. Negative pressure wound therapy (NPWT/VAC) if available. Surgical/plastics review. Osteomyelitis risk — bone biopsy if suspect. Document undermining direction and depth using clock positions.
Unstageable Covered by slough or eschar. Unknown depth. If on heel and dry/stable eschar: protect with dry dressing — do NOT debride. If elsewhere and no infection: autolytic debridement (hydrogel). If infection signs: urgent TVN/surgical referral. Stable heel eschar acts as biological cover. Soften and debride only if fluctuance, erythema, or purulent drainage present.
Infected Wound Erythema >2cm, warmth, purulent discharge, spreading cellulitis, systemic signs. Antimicrobial: silver dressings (Mepilex Ag, Aquacel Ag), iodine dressings (Inadine, Iodoflex). Systemic antibiotics if cellulitis/sepsis. Wound swab (deep tissue preferred over surface swab). MRSA screening per local protocol. Biofilm suspected if no improvement in 2 weeks.
DTPI Intact or non-intact skin, purple/maroon/boggy. Evolving injury. Offload pressure immediately. Thin foam or film if no open area. Once evolves — treat per resulting stage. Monitor closely — may evolve rapidly to Stage 3/4 within days. Document daily. Do not massage — worsens tissue damage.

TIME Wound Assessment Framework

T

Tissue

Identify tissue types: necrotic (black/brown), sloughy (yellow/grey), granulating (red/pink), epithelialising (pink/white edges). Non-viable tissue inhibits healing — requires debridement.

I

Infection / Inflammation

Signs of critical colonisation: delayed healing, increased exudate, pain, friable granulation. Clinical infection: erythema, warmth, purulence, odour, fever. Use antimicrobial dressings; systemic antibiotics if indicated.

M

Moisture Balance

Aim for moist but not wet wound environment. Excess moisture: maceration of wound edges — use more absorbent dressing. Too dry: impairs epithelialisation — use hydrogel or hydrocolloid. Match dressing to exudate level.

E

Edge / Epithelial Advancement

Healthy healing: edges advancing inward (pink epithelial cells). Stalled edges: callous, rolled, or undermined borders suggest wound not progressing. Consider referral, debridement, or NPWT.

Wound Measurement & Documentation

Standardised Measurement Protocol
Length × Width
Measure at greatest length (head-to-toe axis) and greatest width (perpendicular). Record in centimetres. Disposable tape measure per measurement.
Depth
Insert sterile cotton-tipped applicator perpendicular to wound bed at deepest point. Mark level at wound edge and measure. Record if reaches bone.
Tunnelling & Undermining
Use clock face convention. Tunnelling: probe direction and depth (e.g., "tunnelling 3cm at 12 o'clock"). Undermining: document extent at each clock position.
Photography Standards
Perpendicular angle. Metric ruler in frame. Consistent lighting (no flash glare). Include MRN, date, wound location label. Minimum: on admission, weekly, and on each dressing change for Stage 3+.

HAPU vs CAPU Classification

HAPU — Hospital-Acquired Pressure Injury
  • • Any new pressure injury developing AFTER admission
  • • Must be documented on admission skin assessment that it was NOT present
  • • Stage 2+ = Mandatory incident report in GCC hospitals
  • • Stage 3, 4, Unstageable, DTPI = Root cause analysis trigger
  • • Quality indicator tracked by JCI and Ministry of Health
CAPU — Community-Acquired Pressure Injury
  • • Present on admission — must be documented within 24 hours
  • • Photograph and stage on admission
  • • Implement prevention bundle immediately to prevent worsening
  • • Worsening of a CAPU during admission may become reportable
  • • Document clearly: "CAPU — present on admission" in all notes
⚠ Critical: Admission skin assessment MUST be completed within 8 hours of admission (ICU) or 24 hours (ward). Without this, any pressure injury found later will default to HAPU classification.

Never Events & Mandatory Reporting

Potential Never Events (JCI-Accredited GCC Hospitals)

GCC Incident Reporting Thresholds
Injury ClassificationReporting RequirementFollow-Up Action
Stage 2 HAPUMandatory incident report (same shift)Ward manager notification, prevention bundle escalation
Stage 3 HAPUMandatory incident report + RCA triggerRoot cause analysis, quality team involvement
Stage 4 HAPUMandatory incident report + RCA + Sentinel Event reviewFull RCA, executive notification, case review
Unstageable HAPUMandatory incident reportTVN assessment within 24 hrs, RCA if Stage 3/4 on staging
DTPI HAPUMandatory incident reportDaily monitoring, escalation if evolves
Stage 1 HAPUDocument in notes, no formal incident report requiredEscalate prevention bundle immediately

Wound Care Referral Pathways

Tissue Viability Nurse (TVN)

Refer for: Stage 2+ not healing in 2 weeks, Stage 3/4, Unstageable, DTPI, complex dressing needs, MDRPI, suspected biofilm

Plastic Surgery

Refer for: Stage 4 with exposed bone/tendon, surgical debridement needed, wound closure consideration (flap/graft), osteomyelitis

Nutrition Team / Dietitian

Refer for: MUST score ≥1, BMI <18.5, existing Stage 2+ injury, poor oral intake, on tube feeding, bariatric patients

Physiotherapy

Refer for: Immobile patients requiring repositioning assistance programme, rehabilitation, muscle strengthening to improve mobility and self-repositioning

Quick Reference

STAR Skin Tear Classification

  • Type 1a: linear — flap covers wound bed
  • Type 1b: flap covers <75% wound bed
  • Type 2a: flap pale/darkened, covers wound bed
  • Type 2b: flap pale/darkened, covers <75%
  • Type 3: flap absent — entire wound exposed

MASD vs Pressure Injury

  • MASD: diffuse, irregular edges, no bony prominence
  • MASD: periwound satellite lesions, bilateral
  • PI: over bony prominence, staged depth
  • PI: usually unilateral, defined borders
  • Key: consider both — can co-exist

Braden Score Quick Ref

  • ≤9: Very High Risk — q2hr reposition, dynamic mattress, TVN
  • 10–12: High Risk — q2hr reposition, dynamic mattress
  • 13–14: Moderate — q2hr, foam mattress
  • 15–18: Mild — q4hr, foam or reactive mattress
  • 19–23: No additional interventions unless clinical signs

Repositioning Positions

  • Supine: 0° (only if medically required)
  • Semi-recumbent: 30° lateral tilt (preferred)
  • Avoid: full 90° lateral (trochanter pressure)
  • Semi-Fowler: HOB 30° max
  • Prone: assess sacrum/face every 2 hrs

Knowledge Check — 10 MCQs

1. A patient has intact skin with non-blanchable erythema over the sacrum. There is no open wound. What is the correct stage?
2. A patient's heel has stable dry eschar with no signs of infection. What is the correct management?
3. A Braden Scale score of 11 indicates which risk category?
4. Which of the following is NOT a component of the SSKIN bundle?
5. A pressure injury where bone is visible and palpable at the wound base is classified as:
6. When elevating heels to prevent pressure injury, where should the pillow be placed?
7. The Friction & Shear subscale of the Braden Scale has a maximum score of:
8. A patient develops purple, boggy intact skin over the left heel. This most likely represents:
9. The "T" in the TIME wound assessment framework stands for:
10. In GCC JCI-accredited hospitals, a Stage 3 hospital-acquired pressure injury triggers:
Your Score