Safety and infection control

Pressure injuries and falls: staging, risk and prevention

The pressure injury stages, the Braden risk bands, and the prevention measures that are right and the ones that are classic wrong answers.

8 min read·foundation·

Reviewed by a licensed nurse · 25 October 2026

Stages of pressure injury

Stage	What you see
Stage 1	Intact skin with non-blanchable redness over a bony area
Stage 2	Partial-thickness loss with exposed dermis. Shallow open ulcer or blister. No slough.
Stage 3	Full-thickness skin loss. Fat is visible. Slough or eschar may be present. No muscle or bone.
Stage 4	Full-thickness loss with exposed or palpable muscle, tendon, ligament, cartilage or bone
Unstageable	Base covered by slough or eschar so the depth cannot be seen
Deep tissue injury	Persistent deep red, maroon or purple discoloration of intact or broken skin

Staging describes the deepest tissue seen. A healing injury is not "restaged" to a lower stage.

The scale scores sensory perception, moisture, activity, mobility, nutrition and friction and shear. A lower score means higher risk.

·Turn and reposition on a schedule set by the plan of care, using a 30-degree side-lying position rather than lying flat on the hip bone.
·Float the heels off the bed with a pillow under the calves.
·Keep skin clean and dry, and manage moisture from incontinence.
·Use a pressure-redistributing mattress or chair cushion.
·Encourage protein and fluid intake and report poor intake.
·Lift, do not drag, the client in bed to avoid friction and shear.

·Use a fall risk tool on admission and when the condition changes.
·Keep the bed in the lowest position with the brakes locked and the call light within reach.
·Orient the client to the room and offer toileting regularly.
·Do not use side rails or restraints as the first measure to prevent falls. They can cause injury.
·After a fall, assess the client first, then notify the RN or prescriber and document.

Check yourself

1. A client has a shallow open area over the sacrum with a pink wound bed and no slough. What stage is this?
2. Which action should the nurse avoid when caring for a client with reddened skin over the hip?
3. A client has a Braden score of 9. How is the risk best described?