Preventing bed sores comes down to reducing prolonged pressure on the skin, keeping skin clean and dry, eating enough protein and calories, and catching early warning signs before they progress. Bed sores, also called pressure injuries, develop when sustained pressure cuts off blood flow to the skin and underlying tissue, typically over bony areas like the tailbone, heels, hips, and shoulder blades. They can form in as little as a few hours in high-risk individuals, and treating a single pressure injury costs anywhere from $20,900 to $151,700. Prevention is far simpler and less painful than treatment.
Who Is Most at Risk
Anyone who spends extended time in a bed or wheelchair without regularly shifting position is at risk. This includes people recovering from surgery, those with spinal cord injuries, older adults with limited mobility, and anyone with conditions that reduce sensation in the skin. The widely used Braden Scale rates a person’s risk across six factors: sensory perception (can you feel discomfort that would prompt you to shift?), moisture exposure, activity level, mobility, nutrition, and friction or shear on the skin. Scores of 18 or below out of 23 signal increased risk, with lower scores meaning higher danger.
You don’t need to formally score yourself or a loved one to recognize the pattern. If someone can’t reposition themselves, has poor appetite, deals with incontinence, or has thin or fragile skin, they need a prevention plan in place immediately.
Repositioning: The Single Most Important Step
Changing position regularly is the cornerstone of prevention. For someone lying in bed, repositioning every two to three hours is the standard recommendation when they’re also on an appropriate support surface. Intervals of four hours or longer are not recommended for people at risk. For someone sitting in a wheelchair, weight shifts should happen more frequently, ideally every 15 to 30 minutes, because seated posture concentrates pressure on a smaller area.
Repositioning isn’t just rolling from one side to the other. The 30-degree lateral tilt is preferred over lying fully on the side at 90 degrees. At 30 degrees, the body’s weight spreads across a larger area, reducing the pressure on any single bony point. To achieve this, place a pillow or wedge behind the person’s back so they’re angled slightly, not flat on their back and not fully on their hip. Alternate between tilting left, tilting right, and lying on the back.
The best repositioning schedule accounts for the full 24-hour day, including sleep. A written schedule posted near the bed helps caregivers stay consistent. That said, the ideal interval varies from person to person based on their skin tolerance, mobility, weight, and what kind of mattress they’re using. If redness appears between turns, the interval needs to be shortened.
Protecting the Heels
Heels are uniquely vulnerable because they’re small, bony, and bear concentrated pressure when someone lies on their back. The goal is to “float” the heels so they never touch the mattress at all. The most accessible way to do this is to slide a pillow lengthwise under each calf so the heel hangs completely free. Use one pillow per leg, positioned along the full length of the calf but not directly behind the knee, since pressure there can restrict blood flow.
Avoid rolling up a towel or blanket and tucking it under the foot itself. This just transfers pressure to the back of the heel and Achilles tendon. Specially designed heel offloading boots are available for higher-risk patients and should be fitted to the individual’s foot size. If you’re using a boot, don’t add a pillow under the knee, as this can push the heel down into the boot and defeat its purpose. A simple check: slide your hand under the device. If you can’t feel a gap between the heel and the mattress, the heel isn’t floating.
Choosing the Right Mattress or Cushion
Standard hospital or home mattresses aren’t designed to manage pressure. Pressure redistribution surfaces fall into two categories. Reactive surfaces, like high-density foam or gel overlays, work by spreading the body’s weight across a larger area. They’re quieter, more comfortable for most people, and a good fit for someone who can still shift position on their own or who receives repositioning at least every four hours.
Active surfaces use alternating air cells that inflate and deflate on a cycle, periodically relieving pressure from different parts of the body. These are better suited for people at higher risk or those who can’t be turned frequently enough. The tradeoff is that some people find the shifting sensation uncomfortable or disorienting, and the pumps produce noise that can disrupt sleep. When selecting a surface, consider the person’s comfort preferences, their tolerance for motion and noise, and whether a caregiver is available to monitor and adjust the equipment.
For wheelchair users, a pressure-relieving seat cushion made of foam, gel, or air cells serves the same function. No support surface eliminates the need for repositioning. It supplements it.
Keeping Skin Clean and Dry
Moisture is one of the fastest accelerators of skin breakdown. Sweat, urine, and stool soften the skin’s outer layer, making it far more susceptible to damage from friction and pressure. If someone is incontinent, the affected area needs to be cleaned promptly after each episode, dried thoroughly, and protected with a barrier cream recommended by a healthcare provider.
When washing, use a soft cloth and a gentle cleanser rather than regular soap, which can strip the skin’s natural oils and alter its pH. Don’t scrub. Apply moisturizing cream daily to keep skin supple, paying attention to areas under the breasts, in the groin, and between skin folds where moisture collects. Avoid talcum powder, which can cake in creases and irritate the skin.
Bedding and clothing matter too. Use breathable, moisture-wicking fabrics when possible. Change sheets and incontinence pads as soon as they become damp. Wrinkled sheets create ridges that concentrate pressure and friction on small areas of skin, so smooth them out each time you reposition someone.
Nutrition and Hydration
Skin and tissue need adequate fuel to stay resilient and repair minor damage before it becomes a wound. Protein is especially critical because the body uses it to maintain and rebuild tissue. People at risk of pressure injuries need more protein than the standard dietary recommendation, though the exact amount depends on their body weight, overall health, and whether a wound has already formed.
Calories matter just as much. If someone isn’t eating enough to maintain their weight, their body starts breaking down muscle and fat stores, which thins the tissue cushioning bony prominences. For someone with a poor appetite, smaller and more frequent meals, nutrient-dense snacks, and oral nutrition supplements can help close the gap. Staying well hydrated keeps skin more elastic and less prone to cracking. If a loved one is losing weight or eating very little, a dietitian can assess their specific needs and recommend a targeted plan.
Reducing Friction and Shear
Friction happens when skin drags across a surface, like when someone is pulled up in bed rather than lifted. Shear occurs when the skin stays in place while deeper tissue shifts underneath, which commonly happens when the head of the bed is raised and the person slowly slides downward. Both damage blood vessels and weaken skin.
To minimize friction, lift rather than drag when repositioning. Use a draw sheet (a flat sheet folded under the person’s torso) so two caregivers can lift together. Keep the head of the bed elevated no higher than 30 degrees when possible, since steeper angles increase shear forces on the tailbone. If the bed must be raised higher for eating or breathing, try to limit the duration and reposition afterward. Applying a thin skin protectant to vulnerable areas can also reduce surface friction.
Spotting a Stage 1 Pressure Injury Early
The earliest sign of a developing pressure injury is a patch of redness over a bony area that doesn’t fade when you press on it. On lighter skin, this is straightforward to see. On darker skin tones, the discoloration may appear purple, blue, or simply different from the surrounding skin, and the blanching test may not produce a visible color change.
To check, press a fingertip firmly on the red area for a few seconds, then release. Healthy skin briefly turns white (blanches) and quickly returns to its normal color. If the redness stays put, that’s non-blanchable erythema, the hallmark of a Stage 1 pressure injury. The spot may also feel warmer, cooler, firmer, or softer than the skin around it, and the person may report pain or tenderness there. If redness persists for more than 20 minutes after pressure is relieved, the tissue is already damaged.
Check the skin at every repositioning, paying close attention to the sacrum, heels, hips, shoulder blades, and the back of the head. Catching a Stage 1 injury early and immediately offloading that area can prevent it from progressing to an open wound.