Bed sores, also called pressure injuries, are largely preventable with consistent daily care. About 1 in 10 nursing home residents develops at least one pressure sore during a given year, and broader data suggests nearly 29% of long-term care residents experience them over time. The good news is that a combination of repositioning, proper nutrition, skin care, and the right mattress can dramatically reduce that risk.
Why Pressure Injuries Develop
Pressure injuries form when sustained force compresses the skin and underlying tissue against a bony surface like the tailbone, hip, or heel. This compression cuts off blood flow, and without oxygen, the tissue starts to break down. The process can begin in as little as two hours of uninterrupted pressure on a single spot.
Three forces work together to cause damage: direct pressure from body weight, shear (when layers of tissue slide against each other, like when someone slides down in bed), and friction from skin dragging across sheets. Moisture from sweat or incontinence weakens the skin’s outer layer, making all three forces more destructive.
Spotting Early Warning Signs
The earliest sign of a pressure injury is a patch of redness that doesn’t fade when you press on it with a finger. On darker skin tones, color changes can be harder to see visually, so check for differences in temperature, firmness, or tenderness compared to surrounding skin. This is a Stage 1 injury, and the skin is still intact. Caught here, it’s fully reversible with pressure relief.
A Stage 2 injury looks like a shallow open wound with a pink or red wound bed, or it may appear as an intact or ruptured blister filled with clear fluid. At this point, the outer layer of skin has broken down. Check high-risk areas daily: the tailbone, hips, heels, shoulder blades, back of the head, and the skin behind the ears if oxygen tubing is in use.
Repositioning: The Single Most Important Step
Changing position every two to three hours is the foundation of pressure injury prevention. International clinical guidelines recommend repositioning at two- or three-hour intervals for anyone at risk, provided they are on an appropriate pressure-redistribution mattress. Extending that interval to four hours or longer is not recommended.
When repositioning someone in bed, alternate between their back, left side, and right side. When on their side, tilt them at roughly a 30-degree angle rather than directly onto the hip bone. This distributes weight across a broader area. For someone in a wheelchair, encourage frequent weight shifts throughout the day. Even small movements, like leaning side to side or pressing up with the arms, relieve pressure on the sitting bones.
One critical detail: keep the head of the bed at or below 30 degrees whenever medically possible. Raising it higher causes the body to slide downward, creating shear forces on the tailbone that are just as damaging as direct pressure.
Lifting, Not Dragging
Every time you pull someone up in bed or transfer them to a chair, their skin can drag across the sheets. That friction strips away the outer skin layer and sets the stage for breakdown. Use a draw sheet (a flat sheet folded under the person from shoulders to thighs) and always have two people lift rather than drag. Lay the bed flat before repositioning, then raise it again afterward. Slide sheets, transfer boards, and mechanical lifts all reduce the shearing force on skin during movement.
Choosing the Right Mattress
Any pressure-redistribution mattress outperforms a standard hospital or home mattress. Beyond that, the best choice depends on how much the person can move on their own.
- High-specification foam mattresses use multiple layers or surface cutouts to spread pressure more evenly. They work well for people who can reposition themselves or who receive repositioning at least every four hours.
- Reactive (constant low pressure) air mattresses maximize the contact area between the body and the surface, reducing pressure peaks at bony spots. Evidence suggests they reduce pressure injury risk compared to foam surfaces in both acute and long-term care settings.
- Alternating pressure air mattresses use cells that inflate and deflate in cycles, periodically offloading tissue so blood can flow. These are particularly useful for people who cannot be turned regularly, though some find the shifting sensation uncomfortable.
There is no single mattress that clearly outperforms all others. Regular repositioning narrows the performance gap between mattress types, so even a good foam mattress paired with consistent turning can be highly effective. One important caution: avoid piling extra layers of blankets, pads, or sheets on top of a specialty mattress. Too many layers increase heat, trap moisture, block airflow, and can negate the pressure-relieving properties of the surface underneath.
Protecting the Heels
Heels are especially vulnerable because they’re small, bony, and bear concentrated pressure when someone lies on their back. The recommended approach is “floating heels,” where the heels are lifted completely off the mattress so no pressure touches them at all. Place a pillow lengthwise under the calves to distribute the leg’s weight from below the knee to just above the ankle, leaving the heel suspended in the air.
Avoid rolled-up towels or blankets placed only behind the foot. These concentrate pressure on a small area rather than spreading it along the calf. Medical-grade foam heel boots are another option, but they need to be properly sized and regularly checked. Slip a hand under the boot to confirm the heel is truly floating above the mattress surface. If the boot shifts, the heel can end up pressing directly against the bed, making the device useless. Also, do not add a pillow under the knee when using a heel boot, as this can push the heel back down into contact with the mattress.
Managing Moisture and Skin Care
Moisture from incontinence, sweating, or wound drainage softens the skin and makes it far more susceptible to friction damage. Incontinence-associated dermatitis, a red, irritated rash from prolonged exposure to urine or stool, is a direct pathway to pressure injuries.
Clean the skin promptly after each episode of incontinence using a pH-balanced cleanser rather than regular soap. Soap disrupts the skin’s natural acid mantle, causing dryness and irritation. After cleaning, apply a barrier cream containing zinc oxide to create a protective layer between the skin and moisture. Spray-on barrier creams combined with proper continence management have been shown to heal up to 85% of moisture-related skin lesions within 3 to 28 days.
If incontinence is frequent, consider absorbent products designed to wick moisture away from the skin. Change them as soon as they are soiled rather than on a fixed schedule.
Nutrition That Supports Skin Integrity
Skin needs adequate protein, calories, and specific micronutrients to maintain its structure and repair daily wear. Protein is the most critical macronutrient for skin resilience and wound prevention. Many older adults fall short of their protein needs, especially those with poor appetite, difficulty chewing, or chronic illness. Including a source of protein at every meal (eggs, dairy, fish, beans, or fortified nutrition drinks) helps maintain the tissue reserves that resist breakdown.
Vitamin C plays a direct role in collagen production, the structural protein that gives skin its strength. Citrus fruits, strawberries, bell peppers, and tomatoes are all good sources. Adequate hydration also matters: dehydrated skin loses elasticity and tears more easily.
Identifying Who Is Most at Risk
Healthcare providers use the Braden Scale to assess pressure injury risk. It scores six factors: sensory perception (can the person feel discomfort and shift position?), moisture exposure, physical activity level, mobility, nutritional status, and friction/shear risk. Scores range from 6 to 23, with lower scores meaning higher risk.
- Mild risk: scores of 15 to 18
- Moderate risk: scores of 13 to 14
- High risk: scores of 10 to 12
- Severe risk: a score of 9 or below
You don’t need to formally score your family member to benefit from this framework. Simply thinking through the six categories helps you identify where the vulnerabilities are. Someone who is immobile and incontinent but eating well has a different prevention plan than someone who is mobile but malnourished and losing weight. Tailor your efforts to the specific risk factors present, and revisit them whenever health status changes, because a new illness, surgery, or decline in appetite can shift someone from mild to high risk within days.