Decubitus Ulcer (Pressure Injury)
A decubitus ulcer (also called a pressure injury, pressure sore, or bedsore) is localized damage to the skin and underlying tissue caused by prolonged pressure, friction, or shear, typically over bony prominences. Pressure injuries are classified in stages from Stage 1 (intact skin with non-blanchable redness) to Stage 4 (full-thickness tissue loss exposing bone, muscle, or tendon).
Exam Tip
Stage 1 = non-blanchable redness on intact skin. Follow the individual turning schedule. Most common sites: sacrum and heels. Moisture from incontinence increases risk. Report ALL skin changes immediately. Prevention is a PRIMARY CNA responsibility.
What Is a Decubitus Ulcer (Pressure Injury)?
A decubitus ulcer develops when sustained pressure on the skin reduces blood flow to the tissue, causing cell death. These injuries most commonly occur over bony prominences (sacrum, heels, elbows, hips, shoulders) in patients who are immobile, malnourished, or incontinent. The current preferred term is "pressure injury" (updated by NPUAP in 2016).
Stages of Pressure Injuries
| Stage | Description |
|---|---|
| Stage 1 | Intact skin with non-blanchable redness (does not turn white when pressed); may feel warm or firm |
| Stage 2 | Partial-thickness skin loss with exposed dermis; appears as a shallow open wound or blister |
| Stage 3 | Full-thickness skin loss; fat may be visible, but bone/muscle/tendon are not exposed |
| Stage 4 | Full-thickness tissue loss with exposed bone, muscle, or tendon; may include tunneling |
| Unstageable | Full-thickness loss obscured by slough (yellow) or eschar (black/brown dead tissue) |
| Deep Tissue Injury | Intact or non-intact skin with dark, non-blanchable discoloration; may deteriorate rapidly |
Common Sites (Bony Prominences)
| Position | At-Risk Areas |
|---|---|
| Supine (back) | Sacrum/coccyx, heels, shoulder blades, back of head |
| Lateral (side) | Greater trochanter (hip), ear, ankle, shoulder |
| Prone (face down) | Knees, toes, chest, cheek |
| Sitting | Ischial tuberosities (sit bones), sacrum, shoulder blades |
CNA Responsibilities for Prevention
- Reposition on the individualized care-plan schedule and document
- Inspect skin during care, especially over bony prominences
- Keep skin clean and dry (prompt incontinence care, barrier cream)
- Ensure adequate nutrition and hydration (report poor intake)
- Use proper lifting techniques to avoid friction and shear
- Apply heel protectors and pressure-relieving devices as ordered
- Report ANY skin changes (redness, warmth, open areas) to the nurse immediately
Exam Alert
Pressure injury prevention is one of the most heavily tested CNA topics. Know the stages (especially Stage 1 = non-blanchable redness on intact skin). Follow the individual turning schedule. The sacrum and heels are the most common sites. Moisture from incontinence is a major risk factor. Report all skin changes to the nurse immediately.
CNAs describe and promptly report changes; a qualified clinician assesses and stages the injury. On darker skin, color changes may be subtle, so also report temperature, pain and firmness changes. Official guidance.
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Braden Scale
The Braden Scale is a standardized clinical tool used to assess a patient's risk for developing pressure injuries (bedsores). It evaluates six risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear, with scores ranging from 6 (highest risk) to 23 (lowest risk).
Body Mechanics
Body mechanics refers to the coordinated use of body position, movement, and alignment to prevent injury during patient care activities such as lifting, transferring, and repositioning. Body mechanics are one part of safe handling; dependent patient transfers require suitable equipment and staffing.
Activities of Daily Living (ADLs)
Activities of Daily Living (ADLs) are the fundamental self-care tasks that individuals perform daily, including bathing, dressing, eating, toileting, transferring (mobility), and continence. Assessing ADLs helps nurses determine a patient's functional status and care needs.
Intake and Output (I&O)
Intake and output (I&O) records measured fluid entering and leaving the body over a defined period, often 24 hours. The care team uses it with weight trends and clinical findings to assess fluid balance.
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