HarvardCare at Home 
Wound Care
Preventing Painful and Dangerous Pressure Injuries
Pressure ulcers, commonly called bedsores, are one of the most serious complications affecting people with limited mobility. These wounds develop when sustained pressure cuts off blood flow to skin and underlying tissue, causing damage that ranges from reddened skin to deep wounds exposing muscle and bone.
The good news is that most pressure ulcers are preventable. With consistent attention and proper technique, caregivers can protect their loved ones from these painful, dangerous, and difficult-to-heal wounds.
This daily checklist provides the framework for effective pressure ulcer prevention. Following these steps every day dramatically reduces your loved one’s risk.
Understanding Pressure Ulcer Risk
Before diving into prevention, understanding who is at risk helps you appreciate why consistent prevention matters.
Who Develops Pressure Ulcers
Pressure ulcers can develop in anyone who cannot move freely, but risk is highest for people who are bedridden or wheelchair, those with paralysis or severe weakness, people with reduced sensation who cannot feel discomfort, elderly individuals with fragile skin, those with poor nutrition or dehydration, people with incontinence, and those with conditions affecting circulation.
How Quickly Damage Occurs
Pressure damage can begin within hours of sustained pressure. By the time visible changes appear, significant damage may already exist beneath the surface. This is why prevention must be consistent and proactive rather than reactive.
Common Locations
Pressure ulcers typically develop over bony prominences where pressure concentrates. High-risk areas include the sacrum and tailbone, hips, heels, shoulder blades, back of the head, ears when lying on the side, and elbows and ankles.
The Daily Prevention Checklist
Use this checklist every day to ensure all prevention measures happen consistently.
Morning Routine
Complete Skin Inspection
Check all skin, especially pressure-prone areas, every morning. Look for redness that does not fade when pressed, areas that feel warmer or cooler than surrounding skin, areas that feel firmer or softer than normal, any skin discoloration, blisters or broken skin, and any changes from yesterday.
For people with darker skin, pressure damage may appear as purple, blue, or ashen areas rather than red.
Document What You Find
Keep a simple log of skin condition. Note any areas of concern. Track whether areas of redness resolve with pressure relief or persist. This documentation helps identify developing problems early.
Morning Repositioning
If your loved one has been in the same position overnight, reposition them as part of the morning routine. Note the time and position in your log.
Morning Hygiene
Complete personal hygiene, paying attention to keeping skin clean and dry. Check for any incontinence that occurred overnight and clean thoroughly. Apply moisture barrier products if appropriate. Apply moisturizer to dry skin areas, avoiding areas between toes.
Throughout the Day: Repositioning
The Two-Hour Rule
Reposition your loved one at least every two hours while in bed. Some people with very fragile skin or existing pressure damage may need more frequent repositioning.
Position Rotation
Rotate through multiple positions including back, right side at 30 degrees, left side at 30 degrees, and other positions as tolerated. Avoid positioning directly on the hip bones. The 30-degree lateral position distributes pressure better than 90-degree side-lying.
Proper Repositioning Technique
Use a draw sheet to lift and turn rather than dragging. Dragging creates friction that damages skin. Support the position with pillows to prevent rolling back. Ensure the new position maintains body alignment.
For Wheelchair Users
People in wheelchairs should shift position every 15 to 30 minutes. If unable to shift independently, reposition them or have them stand briefly if able. Weight shifts can be side to side, forward, or lifting with arms if able.
Document Every Reposition
Keep a turning schedule log. Check off each reposition with time and position. This ensures consistency, especially when multiple caregivers are involved.
Throughout the Day: Heel Protection
Why Heels Need Special Attention
Heels are extremely vulnerable to pressure damage. The small surface area concentrates pressure intensely, and the limited tissue padding provides little protection.
Float the Heels
Heels should be completely off the mattress whenever your loved one is in bed. Place pillows under the calves so heels float freely without touching the bed. Check frequently that heels have not settled back onto the mattress. Consider heel protector devices for additional protection.
Check Heels Regularly
Inspect heels at every reposition and during skin checks. Look at the back and sides of heels where pressure occurs.
Throughout the Day: Moisture Management
Why Moisture Matters
Wet skin is weaker and more susceptible to damage. Moisture from incontinence, perspiration, or wound drainage dramatically increases pressure ulcer risk.
Incontinence Care
Check for incontinence frequently, at least every two hours. Change wet or soiled briefs immediately. Clean skin thoroughly after each episode. Apply moisture barrier cream to protect skin. Consider scheduled toileting if your loved one has some ability to participate.
Perspiration Management
Keep the room comfortably cool. Use breathable fabrics for clothing and bedding. Change damp clothing and linens promptly. Consider moisture-wicking products for heavy perspiration.
Dressing and Wound Drainage
If your loved one has wounds, ensure dressings contain drainage effectively. Change dressings that become saturated. Protect surrounding skin from drainage exposure.
Mealtime: Nutrition for Skin Health
Protein at Every Meal
Protein is essential for maintaining skin integrity. Include protein-rich foods at every meal including eggs, meat, fish, poultry, dairy, beans, and nuts. Consider protein supplements if dietary intake is inadequate.
Adequate Calories
Underweight individuals have less tissue protecting bony prominences. Ensure adequate calorie intake to maintain healthy body weight.
Hydration
Offer fluids frequently throughout the day. Dehydrated skin is more fragile and susceptible to breakdown. Unless fluids are restricted for medical reasons, encourage liberal intake.
Key Nutrients
Ensure adequate intake of vitamin C for collagen formation, vitamin A for skin health, zinc for tissue repair, and adequate overall nutrition to fuel body processes.
Evening Routine
Evening Skin Check
Perform another complete skin inspection during evening care. Compare to morning findings. Note any areas that have developed redness during the day. Assess whether morning areas of concern have improved or worsened.
Evening Hygiene
Complete evening personal care with attention to keeping skin clean, dry, and moisturized. Address any incontinence. Apply barrier products as appropriate.
Positioning for Sleep
Set up your loved one in a comfortable position with appropriate pressure redistribution. Ensure heels are floated off the mattress. Position pillows to maintain alignment and prevent pressure between knees and ankles. Plan overnight repositioning schedule.
Overnight Care
Overnight Repositioning
Repositioning should continue overnight. Every two hours remains the standard. Set alarms if needed to wake for repositioning. If repositioning every two hours is not feasible, use the best pressure-redistributing mattress available and reposition as frequently as possible.
Incontinence Checks
Check for incontinence during overnight repositioning. Change immediately if wet or soiled.
Equipment and Supplies
Pressure-Redistributing Surfaces
The right mattress reduces pressure ulcer risk significantly. Options include high-density foam mattresses, alternating pressure mattresses, low air loss mattresses, and specialty overlays.
Discuss appropriate options with healthcare providers based on your loved one’s risk level.
Positioning Aids
Keep positioning supplies readily available including pillows of various sizes, foam wedges, heel protectors, and positioning devices appropriate for your loved one’s needs.
Skin Care Products
Stock gentle cleansers, moisturizers for dry skin, moisture barrier products for incontinence, and products recommended by your healthcare provider.
When to Seek Professional Help
Despite best prevention efforts, skin problems sometimes develop. Early professional intervention prevents serious complications.
Contact Healthcare Providers If You Notice
Redness that does not fade within 30 minutes of pressure relief, any open area or blister, skin that appears purple, blue, or black, any area that is significantly warmer, cooler, firmer, or softer than surrounding tissue, any signs of infection such as increased warmth, drainage, or odor, or any skin change that concerns you.
Professional Support for Prevention
If your loved one is at high risk for pressure ulcers, professional support can strengthen your prevention efforts.
Skilled nursing provides professional skin assessment, identifies risk factors, and recommends prevention strategies. A wound care nurse offers specialized expertise in skin protection and wound prevention.
If pressure ulcers do develop, professional pressure ulcer care at home provides expert treatment. For advanced wounds, specialized care like wound vac therapy may be needed.
Therapy Support
Physical therapy can help maintain whatever mobility your loved one has. Occupational therapy addresses positioning and daily activities. Both can reduce pressure ulcer risk by optimizing function.
Caregiver Education
Caregiver training teaches proper positioning, transfer techniques, and skin care, giving you confidence and skills for effective prevention.
Making Prevention Routine
Consistency is the key to pressure ulcer prevention. Build these tasks into your daily routine until they become automatic.
Create a Written Schedule
Post a repositioning schedule where caregivers can see it. Use check-off logs to ensure nothing is missed. Review the schedule to ensure it is being followed.
When Multiple Caregivers Are Involved
Ensure everyone understands and follows the prevention plan. Communicate clearly between shifts. Use shared logs so everyone knows what has been done and what is needed.
Adjust as Needed
If your loved one’s condition changes, reassess prevention needs. More fragile skin may need more frequent repositioning. New mobility limitations require updated strategies. Communicate changes to all caregivers.
The Prevention Commitment
Pressure ulcer prevention requires daily commitment and consistent effort. It may feel tedious at times. But the alternative, a painful, slow-healing wound that significantly impacts quality of life and can lead to serious complications, makes every prevention effort worthwhile.
By following this daily checklist, you protect your loved one from suffering that is largely preventable. Your consistent attention and care make the difference between healthy skin and a devastating wound.
