Most people know them as bedsores, but whatever you call pressure injuries, the ulcers that form on the skin from extended periods of immobility are frustrating, painful experiences for patients during extended hospital stays, particularly those older and frailer. Unfortunately, bedsores can also become a source of infection and contribute to worsening conditions when not adequately treated or, when possible, prevented. 

While anyone who spends a long period in bed is at risk for pressure injuries, those with diabetes, poor nutrition, obesity, or circulation problems are at higher risk. The risk also increases if the patient is positioned poorly and isn’t turned periodically, especially those unconscious or incapable of moving themselves. With Covid-19, prone positioning is recommended for acute respiratory distress based on multiple randomized controlled trials that showed improved oxygenation and reduced risk of death in this position. Still, prone positioning also presents challenges for preventing bedsores. The National Pressure Injury Advisory Panel offers a PDF handout on preventing prone positioning pressure injuries that you can easily print and hang somewhere in the nurse station. 

‍Stages of Pressure Injuries

Pressure injuries are caused by more than prolonged contact with a surface. They can also occur with friction, such as when a healthcare provider changes a patient’s position, especially if their skin is moist. Shear—when the patient moves in the opposite direction as the surface, such as sliding down a bed—can also cause pressure injuries. It’s important to know the four stages of pressure injuries because stages 3 and 4 are considered “never events” by the Agency for Healthcare Research and Quality. Therefore, no stage 3 or 4 pressure ulcer should occur after admission to a healthcare facility. 

• Stage 1: The skin remains intact but is discolored, typically red in lighter-skinned patients and blue/purple in dark-skinned patients. The area may be warm to the touch, and the patient may complain of itching, burning, or other topical pain. 

• Stage 2: The outer layer of skin is damaged and may look like a blister, open sore, or scrape. It’s typically red or pink and moist. 

• Stage 3: This wound involves more extensive loss of skin, often appearing like a crater because the wound has cut through the fatty layer of skin. However, no bone, muscle, cartilage, tendon, or ligament are showing. 

• Stage 4: The most severe stage involves so much skin and tissue loss that bone, muscle, cartilage, tendon, or ligament is visible in the ulcer. This stage is life-threatening because of the high risk of infection. 

• Unstageable: An unstageable pressure injury may have a full loss of skin tissue, but the bottom of the crater is covered with scabbing or dead tissue, which may be tan, gray, green, brown, or yellow. 

‍Prevention During Prone Positioning

The four primary areas to consider in preventing pressure injuries from developing in the prone position are the head, torso, legs, breasts, and genitalia. If the patient is not on a bed designed explicitly for a prone position, use a pressure redistribution surface and other devices, such as face pillows, to spread out the pressure. Suppose your facility doesn’t have devices for this purpose (or doesn’t have enough). In that case, you can MacGyver them with pillows (or even bunched sheets or folded towels if necessary) that offload the pressure from critical areas. 

Consider the amount of pressure pushing down on these pressure points: 

• Forehead

• Cheeks

• Nose

• Chin

• Clavicle/shoulder

• Elbow

• Chest/breasts

• Genitalia/penis

• Anterior pelvic bones

• Knees

• Tops of feet and toes

Ideally, you should assess the likely pressure at each of these points before moving the patient into the prone position, taking into account their weight, body shape, and any especially tender areas, such as the breasts or penis. Multiple staff—up to four to six people depending on the patient’s size and shape—may be needed to transfer or reposition a patient while avoiding shear or other friction. One way to reduce pressure on the elbows and arms is to use the swimmer position (right arm up and left arm down) and alternate the arms every two hours. 

‍Prevention by Body Region

The National Pressure Injury Advisory Panel (NPIAP) offers tips specific to each body part with the highest risk of pressure injuries. 

For the head, manage moisture and use prophylactic foam dressings under medical devices and on face pressure points, such as the cheekbones, eye bones, and chin. Use thin dressings to avoid adding more pressure, and manage eye care to prevent corneal abrasion. Ensure the patient’s tongue remains in their mouth, using a soft bite block if needed. Shift the patient’s head every two hours and reposition it every four hours, depending on their needs. 

For the torso, use prophylactic foam on pressure points, and ensure EKG leads are on the patient’s back and that all central lines, arterial lines, and cannulas are secured. Keep other tubes and devices away from the skin and protect the surrounding skin with prophylactic dressings as needed. Make sure no unsecured tubes or devices are under the torso. Patients receiving enteral feeding should have feeding turned off one hour before the prone position turn. 

For the legs, use prophylactic foam dressings on pressure points, such as the knees and shins. Ensure no unsecured devices or tubes are under the legs, and align the urinary catheter and/or fecal management device toward the foot of the bed. Offload feet with a pillow or device for that purpose.