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HLT-LPN37-05 · Lesson 5 · 18 clock hours · lab

Pressure Injury Prevention and Wound Care in Older Adults

Objective. Students will stage pressure injuries using the NPIAP classification system, implement evidence-based prevention interventions, and perform a basic wound assessment and dressing change on a simulated wound model.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

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Why Pressure Injuries Matter in Older Adults

Pressure injuries — sometimes called pressure ulcers or bedsores — are a leading cause of preventable harm in older adults. Aging skin is thinner, less elastic, and slower to heal. Reduced mobility, poor nutrition, incontinence, and decreased sensation all raise risk dramatically. As an LPN, you are often the first clinician to detect a new skin breakdown. Early identification and consistent prevention save lives and reduce suffering.

NPIAP Staging Classification

The National Pressure Injury Advisory Panel (NPIAP) provides the standard system used across the United States to describe pressure injury severity. You must know each stage precisely.

Stage 1: Intact skin with a localized area of non-blanchable erythema (redness). The area does not turn white when pressed. Skin is not broken. In darker skin tones, color change may appear as purple or blue discoloration. The area may be painful, firm, soft, warmer, or cooler compared with surrounding tissue.

Stage 2: Partial-thickness skin loss with exposed dermis. The wound bed is pink or red and moist. It may appear as an intact or open/ruptured blister. Adipose (fat) tissue and deeper structures are not visible. No slough or bruising is present.

Stage 3: Full-thickness skin loss. Adipose tissue is visible in the wound. Granulation tissue and rolled wound edges (epibole) are often present. Slough and/or eschar may be visible. No fascia, muscle, tendon, ligament, cartilage, or bone is exposed. Depth varies by anatomical location.

Stage 4: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. Slough and/or eschar may be present. Undermining and tunneling often occur.

Unstageable: Full-thickness skin and tissue loss where the extent of tissue damage cannot be confirmed because slough or eschar obscures the wound bed. Stable eschar on the heel or ischemic limb should not be removed — it serves as a biological cover.

Deep Tissue Pressure Injury (DTPI): Intact or non-intact skin with a localized area of persistent non-blanchable deep red, maroon, or purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. This results from intense or prolonged pressure and shear at the bone–muscle interface. It may evolve rapidly even with optimal treatment.

The Braden Scale

The Braden Scale is the most widely used evidence-based tool for predicting pressure injury risk. It measures six subscales: Sensory Perception, Moisture, Activity, Mobility, Nutrition, and Friction and Shear. Each subscale is scored from 1 (most impaired) to 4 (least impaired), except Friction and Shear, which is scored 1 to 3. The maximum score is 23. Lower scores indicate higher risk. Most facilities use the following general thresholds:

Assess the Braden Scale on admission, after any significant change in condition, and per facility policy.

Prevention Interventions

Evidence-based prevention is your primary responsibility.

Repositioning: Turn and reposition at-risk patients at least every 2 hours when in bed, and every 1 hour when sitting. Use a scheduled turn plan (e.g., left side → back → right side → back). Document each turn. Use positioning wedges or pillows to maintain a 30-degree lateral tilt rather than a full 90-degree side-lying position, which places direct pressure on the trochanter.

Support surfaces: Use pressure-redistribution mattresses and cushions for high-risk patients. These do not replace repositioning.

Skin care: Keep skin clean and dry. Apply a moisture barrier to skin exposed to incontinence. Do not massage reddened bony prominences — this can cause additional tissue damage.

Nutrition: Collaborate with dietary to ensure adequate protein and caloric intake. Dehydration impairs skin integrity.

Heel protection: Elevate heels completely off the bed surface using foam boots or pillows placed under the calves — not under the knee.

Wound Assessment

Document each wound using a consistent format. Measure length × width × depth in centimeters. Measure length as the longest dimension, width perpendicular to length, and depth at the deepest point using a sterile, flexible probe. Also assess and document: wound bed tissue type (granulation, slough, eschar), wound edges, periwound skin condition, exudate (amount, color, odor), and presence of tunneling or undermining (measured using a clock-face orientation).

Dressing Change: Key Steps and Safety

1. Perform hand hygiene before and after the procedure.

2. Explain the procedure to the patient.

3. Assemble supplies; open packages without contaminating contents.

4. Don clean gloves; remove and discard old dressing.

5. Remove soiled gloves; perform hand hygiene; don new clean or sterile gloves per facility policy and wound type.

6. Assess and measure the wound; document findings.

7. Cleanse the wound with normal saline or prescribed solution using gentle pressure — do not scrub.

8. Apply the appropriate dressing (e.g., moisture-retentive hydrocolloid or foam) smoothly, extending at least 1 inch beyond wound edges.

9. Secure and label the dressing with date, time, and your initials.

10. Remove gloves; perform hand hygiene; document.

Safety points: Never recap needles in the wound care area. Report any signs of wound infection (increased redness, warmth, purulent drainage, odor, fever) immediately. Never stage a pressure injury lower than its original stage — pressure injuries heal by granulation, not by reversing stages. An improving Stage 3 wound is documented as a healing Stage 3, not a Stage 2.

Key terms8

NPIAPNational Pressure Injury Advisory Panel — the professional organization that establishes and updates the standard staging classification system for pressure injuries in the United States.
Non-blanchable erythemaRedness of the skin that does not turn white (blanch) when pressed with a finger; a key indicator of Stage 1 pressure injury and tissue damage.
Braden ScaleA validated risk-assessment tool that scores six factors — sensory perception, moisture, activity, mobility, nutrition, and friction/shear — to predict a patient's likelihood of developing a pressure injury; lower scores indicate higher risk.
Deep Tissue Pressure Injury (DTPI)A pressure injury characterized by intact or non-intact skin with persistent non-blanchable deep red, maroon, or purple discoloration caused by damage at the bone–muscle interface; it may evolve rapidly.
Unstageable pressure injuryA full-thickness wound whose true depth cannot be determined because slough or eschar covers the wound bed, preventing accurate staging.
Moisture-retentive dressingA wound dressing (such as a hydrocolloid or foam dressing) designed to maintain a moist wound environment, which supports healing and reduces pain compared with dry dressings.
UnderminingTissue destruction that occurs under intact skin at the wound edges, extending beyond the visible wound margin; measured in centimeters using clock-face orientation.
Pressure redistribution surfaceA specialized mattress, overlay, or cushion designed to spread body weight over a larger area, reducing peak pressure at bony prominences; used to prevent and manage pressure injuries.

Worked examples4

1. Measure wound dimensions: A wound is assessed and found to measure 4.5 cm at its longest point, 3.0 cm perpendicular to that, and 1.2 cm at its deepest point. How is this documented?
  1. Step 1: Identify length as the longest dimension — 4.5 cm.
  2. Step 2: Identify width as the measurement perpendicular to length — 3.0 cm.
  3. Step 3: Identify depth as the deepest point measured with a probe — 1.2 cm.
  4. Step 4: Record in standard order: length × width × depth.
Answer: Document wound dimensions as 4.5 cm × 3.0 cm × 1.2 cm.
2. Calculate Braden Scale score: A patient scores as follows — Sensory Perception: 2, Moisture: 3, Activity: 1, Mobility: 2, Nutrition: 2, Friction and Shear: 1. What is the total score and what risk level does it represent?
  1. Step 1: Add all subscale scores: 2 + 3 + 1 + 2 + 2 + 1.
  2. Step 2: 2 + 3 = 5; 5 + 1 = 6; 6 + 2 = 8; 8 + 2 = 10; 10 + 1 = 11.
  3. Step 3: Total score is 11. Compare to thresholds: 10–12 = High risk.
Answer: Total Braden score is 11, indicating High risk for pressure injury development.
3. Determine repositioning frequency: A patient on bed rest is to be turned every 2 hours starting at 8:00 AM. List the next four repositioning times and the positions in a left → back → right → back cycle beginning with left side.
  1. Step 1: Start position at 8:00 AM — left side.
  2. Step 2: Add 2 hours: 10:00 AM — back (supine).
  3. Step 3: Add 2 hours: 12:00 PM — right side.
  4. Step 4: Add 2 hours: 2:00 PM — back (supine).
  5. Step 5: The cycle then repeats. Document each turn in the patient's chart.
Answer: Repositioning times are: 8:00 AM (left side), 10:00 AM (back), 12:00 PM (right side), 2:00 PM (back), and so on in repeating sequence.
4. Tunneling measurement: Tunneling is assessed and found to extend 2.5 cm at the 12 o'clock position and 1.0 cm at the 4 o'clock position. How is this documented correctly?
  1. Step 1: Use the clock-face method — the patient's head is 12 o'clock.
  2. Step 2: Record the depth and clock position for each tunnel separately.
  3. Step 3: Write both measurements clearly in the wound assessment note.
Answer: Document as: Tunneling 2.5 cm at 12 o'clock, 1.0 cm at 4 o'clock.
In class: Lecture and photo-based case review: instructor presents NPIAP stages (Stage 1 through 4, unstageable, deep tissue pressure injury) with clinical photos; students match descriptions to correct stages on a printed worksheet. · Lab practice: students perform a head-to-toe skin assessment on a manikin using a skin assessment guide, document findings on a body diagram, calculate Braden Scale score, and develop a two-turn-schedule repositioning plan. · Wound-care dressing change simulation: using a wound care task trainer or foam wound model, students perform hand hygiene, apply sterile/clean technique per facility type, measure wound dimensions, and apply a simulated moisture-retentive dressing following step-by-step procedure card.
Materials: NPIAP staging photos and worksheet, manikin with simulated skin findings, Braden Scale forms, wound care task trainer or foam wound model, dressing supplies (gloves, gauze, moisture-retentive dressing), body diagram handout, measuring tape
Check: Skills checklist: correct staging of five sample wounds (5/5), complete Braden Scale with accurate risk level, dressing change completed in correct sequence with no sterile-field breaks; pass = 80% checklist and 5/5 staging accuracy.

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Physiological Adaptation
1. A nurse observes an area of intact skin over a patient's sacrum that is red and does not blanch when pressed. There is no break in the skin. Which NPIAP stage does this represent?
Physiological Adaptation
2. A patient has a wound with full-thickness skin loss. Adipose tissue is visible, but no tendon, bone, or muscle is exposed. Which stage is correct?
Safety and Infection Control
3. A patient's heel has a thick black eschar that is dry and adherent. There is no redness, warmth, or drainage around the wound. What is the most appropriate nursing action?
Reduction of Risk Potential
4. A patient's Braden Scale score is calculated as follows: Sensory Perception 3, Moisture 2, Activity 2, Mobility 3, Nutrition 3, Friction and Shear 2. What is the total score?
Basic Care and Comfort
5. Which action is most appropriate when caring for a patient who has redness over the greater trochanter?
Safety and Infection Control
6. During a dressing change, the nurse accidentally contaminates a sterile glove by touching the bedside rail. What is the correct next action?
Physiological Adaptation
7. An older adult patient's pressure injury was previously documented as a Stage 3. The wound now has granulation tissue filling most of the wound bed and the depth has decreased. How should the nurse document the current wound stage?
Basic Care and Comfort
8. Which intervention is most important to include in a repositioning plan for a bedbound older adult at high risk for pressure injury?
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