A client is at risk for pressure injuries (pressure ulcers) due to prolonged bed rest. What is the PRIMARY nursing intervention?

PRESSURE INJURIES (formerly called pressure ulcers or decubitus ulcers) are localized areas of injury to the skin and/or underlying tissue, usually over a bony prominence, resulting from sustained pressure, shear, or friction.

Pathophysiology: pressure compresses capillaries, reducing blood flow; ischemia leads to tissue death; prolonged pressure (even low pressure over time) causes injury; highest-risk areas: sacrum/coccyx, heels, greater trochanter, ischial tuberosities, occiput, medial and lateral malleoli, elbows, scapulae. STAGING (NPUAP/EPUAP):

Stage 1: non-blanchable erythema of intact skin — early warning sign.

Stage 2: partial-thickness skin loss, shallow open ulcer with red/pink wound bed.

Stage 3: full-thickness skin loss, subcutaneous fat visible.

Stage 4: full-thickness tissue loss, bone, tendon, or muscle visible.

Unstageable: full-thickness but covered by slough/eschar.

Deep tissue injury: intact skin with discoloration/blood-filled blister.

Primary interventions: REPOSITIONING every 2 hours (or per individualized schedule based on tissue tolerance and patient condition); documentation of position changes; SKIN INSPECTION with each repositioning (especially bony prominences).

Keep skin clean and dry: moisture (incontinence, sweat) dramatically increases skin breakdown; use moisture barriers (zinc oxide).

Minimize friction and shear: use lift sheets for repositioning, not dragging.

Pressure redistribution: specialty mattresses (foam, air-fluidized, low-air-loss); heel protectors.

Nutrition and hydration: protein critical for tissue repair (target adequate protein intake); adequate fluids; nutritional supplements if needed.

Braden scale: most common standardized risk assessment tool (scores sensory perception, moisture, activity, mobility, nutrition, friction/shear; score ≤18 indicates risk).