Pressure ulcers, now formally called pressure injuries, affect roughly 3% to 34% of hospital patients worldwide, with U.S. rates ranging from 8% to 40% depending on the facility and patient population. The good news: most of these injuries are preventable with a combination of repositioning, proper surfaces, skin care, nutrition, and protective devices. Whether you’re a patient, a family member advocating for someone in the hospital, or a healthcare worker, understanding these strategies can make a real difference.
Why Hospital Patients Are So Vulnerable
Pressure injuries happen when sustained force on the skin, usually over a bony area like the tailbone, heels, or hips, cuts off blood flow to the tissue. In a hospital bed, patients who can’t move easily due to surgery, sedation, or illness are at the highest risk. Six factors determine that risk: how well a patient can sense discomfort (which prompts shifting position), how much moisture their skin is exposed to, their activity level, their ability to move independently, their nutritional status, and how much friction and shearing force their skin endures against sheets or chair surfaces.
Hospitals use a standardized scoring tool called the Braden Scale to assess these six factors. A total score of 18 or below signals some level of risk: 15 to 18 is mild, 13 to 14 moderate, 10 to 12 high, and 9 or below severe. The lower the score, the more aggressive the prevention plan needs to be. If you’re caring for someone in the hospital, you can ask the nursing team what their Braden score is and what prevention measures are in place.
Repositioning: The Single Most Important Step
Regularly changing a patient’s position is the cornerstone of pressure injury prevention. For patients at general risk, repositioning at least every six hours is the minimum recommendation. For those at high risk, that interval drops to every four hours. In practice, many hospital protocols call for turning patients every two hours, particularly in intensive care settings where patients are completely immobile.
Repositioning isn’t just about flipping someone from their back to their side. It means shifting the areas of the body that bear weight so no single spot stays compressed for too long. For patients in chairs or wheelchairs, this means shifting weight or being helped to reposition frequently, since sitting concentrates pressure on a smaller surface area than lying down. Small adjustments, like tilting to one side with a pillow or slightly elevating one hip, count. The goal is to restore blood flow to compressed tissue before damage begins.
Pressure-Relieving Mattresses and Surfaces
The standard hospital mattress does very little to distribute a patient’s weight evenly. Specialty pressure-relieving surfaces fall into two broad categories. The first type, called constant low-pressure surfaces, works by spreading body weight across a larger area. These include high-specification foam mattresses, gel overlays, water-filled surfaces, and static air mattresses. They’re passive, meaning they don’t require electricity or mechanical action.
The second type, alternating-pressure mattresses, goes a step further. These electrically powered surfaces have air cells that inflate and deflate in cycles, continuously shifting where pressure falls on the body. This reduces both the intensity and duration of pressure on any given spot. Clinical trials have compared these two approaches extensively, with alternating-pressure mattresses generally reserved for patients at higher risk or those who already have early-stage injuries. If your loved one is at elevated risk, it’s worth asking whether a specialty mattress has been placed on their bed.
Protecting the Heels
Heels are the second most common site for hospital-acquired pressure injuries, right after the sacrum (the base of the spine). The heel has very little padding between the skin and bone, making it especially vulnerable when a patient is lying on their back. Effective heel protection means completely removing pressure from the heel, not just cushioning it.
The simplest method is placing a pillow or foam wedge under the calf so the heel floats above the mattress surface with no contact at all. Hospitals also use heel suspension boots, troughs, and splints designed specifically for this purpose. These devices cradle the lower leg while keeping the heel entirely offloaded. What doesn’t work well is simply placing a soft pad under the heel, since even reduced pressure over many hours can cause damage.
Prophylactic Foam Dressings
Applying silicone foam dressings over high-risk areas before an injury develops is one of the more effective newer strategies. A meta-analysis of ten randomized trials involving nearly 5,000 patients found striking results: silicone foam dressings reduced Stage 1 sacral pressure injuries by 82% and Stage 1 heel injuries by 70% compared to standard care alone. For more severe injuries (Stage 2 and above), sacral injuries dropped by 58% and heel injuries by about 48%.
These dressings work by redistributing pressure and shear forces across a broader area while also managing moisture. They’re applied preventively to the sacrum, heels, or other bony prominences in patients identified as high risk. They’re soft, breathable, and generally well tolerated. If a patient is going to be immobile for an extended period, particularly after surgery or during an ICU stay, these dressings are a reasonable measure to request.
Skin Care and Moisture Management
Moisture from incontinence, sweating, or wound drainage weakens the skin and makes it far more susceptible to breakdown. Incontinence is one of the biggest risk multipliers. When urine or stool sits on the skin, it raises the pH, strips away the skin’s natural protective acid layer, and creates an environment ripe for irritation and tissue damage.
Prevention hinges on prompt cleaning after every episode of incontinence using a no-rinse cleanser with a pH between 4.0 and 6.8, which preserves the skin’s natural acidity. Traditional soap and water should be avoided because they’re too alkaline and strip the skin’s oils. The skin should be patted dry gently, never rubbed, and a barrier product applied immediately. Effective barriers include creams containing dimethicone, petroleum, lanolin, or zinc oxide. These create a moisture-repellent layer that shields the skin from irritants. For patients with frequent incontinence, absorbent pads should be changed regularly so the skin stays as dry as possible.
Nutrition Makes a Bigger Difference Than You’d Think
Skin and tissue need adequate fuel to resist breakdown and repair microscopic damage from pressure. Malnourished patients are significantly more likely to develop pressure injuries, and poor nutrition is one of the six risk factors formally assessed in every hospitalized patient. For patients at risk who also show signs of malnutrition, clinical guidelines recommend 30 to 35 calories per kilogram of body weight per day and 1.25 to 1.5 grams of protein per kilogram per day. For a 150-pound person, that translates to roughly 2,000 to 2,400 calories and 85 to 100 grams of protein daily.
Adequate hydration matters too, with a target of about 30 milliliters of water per kilogram of body weight. For many hospitalized patients, especially older adults, meeting these targets is a challenge. Loss of appetite, nausea from medications, or restrictions from medical procedures can all interfere. If your family member isn’t eating well, raising this with the care team can prompt a dietary consultation. Nutritional supplements, protein-enriched foods, and adjusted meal timing can all help close the gap.
Recognizing Early Warning Signs
The earliest sign of a pressure injury is a Stage 1 injury: a localized area of skin, typically over a bony prominence, that appears red (or purple or maroon in darker skin tones) and doesn’t turn white when you press on it. The skin is intact but the damage underneath has already started. At Stage 2, the skin breaks open into a shallow wound or fluid-filled blister. Stage 3 involves full-thickness skin loss where fat may be visible, and Stage 4 extends deeper to expose muscle, tendon, or bone.
About 90% of hospital-acquired pressure injuries are caught at Stage 1 or Stage 2, which is encouraging because these earlier stages are far more treatable and reversible. The key is catching them before they progress. Daily skin checks over bony areas, particularly the sacrum, heels, shoulder blades, and the back of the head, should be part of routine care for any patient with limited mobility.
The Cost of Getting Prevention Wrong
Beyond the pain and complications for patients, pressure injuries carry an enormous financial burden. Each hospital-acquired pressure injury adds an average of $10,708 in treatment costs per patient, driven primarily by extended hospital stays. Across the United States, the total annual cost reaches an estimated $26.8 billion, with the most severe Stage 3 and 4 injuries accounting for a disproportionate share. Since 2008, Medicare has not reimbursed hospitals for the additional cost of treating pressure injuries that develop during a hospital stay, classifying them as preventable complications. This creates a strong financial incentive for hospitals to invest in prevention, but gaps in implementation remain common.
For patients and families, being informed and proactive is the best defense. Asking about risk scores, repositioning schedules, mattress types, and skin care protocols isn’t overstepping. It’s exactly the kind of engagement that helps close the gap between what prevention guidelines recommend and what actually happens at the bedside.