What are the 2025 Most Crucial Preventative Strategies for Pressure Injuries and Their Evidence Base?

The most crucial preventative strategies for pressure injuries are outlined in the “Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide Prevention Recommendations 2025,” part of the International Clinical Practice Guideline. These strategies are supported by various levels of evidence, including systematic reviews with meta-analysis (Tier 1), systematic reviews without meta-analysis (Tier 2), randomized controlled trials (Tier 3A), and other study designs or clinical expertise (Tier 3B, 3C).

Pressure injuries are localized damage to the skin and/or underlying tissue, often occurring over bony prominences or due to medical devices, and result from prolonged pressure or pressure combined with shear. The development of pressure injuries involves complex pathophysiological theories, including localized ischemia, reperfusion injury, impaired lymphatic drainage, and direct cell deformation.

Key Preventative Strategies and Their Evidence Base

Nutrition in Pressure Injury Prevention

• It is good practice to conduct nutrition screening for individuals at risk of pressure injury.
• It is good practice to conduct a comprehensive nutrition assessment for those screened at risk of malnutrition and develop an individualized care plan.
• It is good practice to encourage consumption of a balanced diet with nutrient-dense food and adequate hydration.
• Nutritional supplementation is suggested for malnourished individuals or those at risk of malnutrition when dietary intake is insufficient (conditional recommendation, very low certainty of evidence based on Tiers 1, 2, 3A).
• Protein supplementation is suggested for individuals at risk of pressure injuries who are malnourished or at risk of malnutrition (conditional recommendation, very low certainty of evidence based on Tiers 1, 2, 3A).
• Carbohydrate-based energy and micronutrient supplementation should be reserved for individuals with known malnutrition or micronutrient deficiencies, in addition to protein needs (conditional recommendation, very low certainty of evidence based on Tiers 1, 2, 3A).
• Tube feeding is strongly recommended against for the specific purpose of preventing pressure injuries in individuals with or at risk of malnutrition (strong recommendation, very low certainty of evidence based on Tiers 1, 2, 3A). This does not apply to individuals already receiving tube feeding as part of usual clinical care or critically ill, pediatric, and neonatal populations where it is a requirement.
• It is good practice to maintain and promote oral nutrition, with decisions regarding tube feeding being preceded by a comprehensive, multidisciplinary assessment.

Repositioning for Preventing Pressure Injuries

• It is good practice to reposition individuals at risk of pressure injuries regardless of the type of support surface used, adjusting intervals based on the surface and individual response. No support surface entirely replaces repositioning.
• It is good practice to reposition in a way that optimizes offloading of pressure points and maximizes pressure redistribution.
• It is good practice to use specialized equipment to reduce friction and shear during repositioning.
• It is good practice to use an individualized repositioning regimen.
• Individualized repositioning intervals should be determined based on factors like activity level, mobility, ability to self-reposition, skin and tissue tolerance, clinical condition, comfort, sleep patterns, care goals, and the support surface in use.
• It is good practice to assess for early skin and tissue injury signs that may indicate a need for more frequent repositioning.
• Repositioning at two or three-hourly intervals is suggested for most individuals at risk, provided they are on an appropriate pressure redistribution full body support surface (conditional recommendation, very low certainty of evidence based on Tiers 1, 2, 3A).
• Routinely extending repositioning intervals to four, five, or six hours is suggested against (conditional recommendation, very low certainty of evidence based on Tiers 1, 2, 3A).
• It is good practice to initiate frequent, small, incremental shifts (micromovements) for critically ill individuals who are too unstable for regular repositioning.
• Using 30-degree lateral positioning is suggested to prevent pressure injury (conditional recommendation, very low certainty of evidence based on Tiers 1, 2, 3A), with individual adjustments for offloading.
• Modifying to a 40-degree lateral position might be necessary. Individualize turning angles to ensure maximum offloading of both the sacrum and the trochanter.  30-degree lateral positioning may not be maintainable or adequately offload the sacrum in individuals with higher body mass index. Modifying to a 40-degree lateral position might be necessary.
• Maintaining head-of-bed elevation at 30 degrees or lower is suggested (conditional recommendation, low certainty of evidence based on Tiers 1, 2, 3A), unless higher elevation is clinically required.
• It is good practice to select a prone position when medically required and cease it as soon as clinically appropriate.
• It is good practice to educate individuals and informal carers on the rationale and significance of repositioning.
• It is good practice to implement repositioning reminder strategies to promote adherence.
• Sensor systems to monitor movement are suggested to assist in evaluating repositioning needs when resources permit (conditional recommendation, very low certainty of evidence based on Tiers 1, 2, 3A).
• An early mobilization program is suggested based on the individual’s activity tolerance (conditional recommendation, very low certainty of evidence based on Tiers 1, 2, 3A).

Full Body Support Surfaces for Prevention of Pressure Injuries

• It is good practice for organizations to maintain an inventory of appropriate full-body support surfaces.
• It is good practice to use a support surface that accommodates the individual’s weight, height, size, and body mass distribution.
• Using a pressure redistribution foam (reactive) full body support surface is strongly recommended for individuals at risk of pressure injuries (strong recommendation, low certainty of evidence based on Tiers 1, 2, 3A).
• It is good practice to consider individual factors when selecting a mattress or support surface, including overall risk, skin response, mobility, posture, microclimate management, and preferences.
• Using either air (reactive) or pressure redistribution foam (reactive) full body support surfaces is suggested for individuals at risk (conditional recommendation, very low certainty of evidence based on Tiers 1, 2, 3A).
• Using either alternating pressure air (active) or pressure redistribution foam (reactive) full body support surfaces is suggested (conditional recommendation, low certainty of evidence based on Tiers 1, 2, 3A).
• Using either alternating pressure (active) air or air (reactive) full body support surfaces is suggested (conditional recommendation, very low certainty of evidence based on Tiers 1, 2, 3A).
• A medical-grade sheepskin could be used where available, but not with full body support surfaces that already have pressure redistribution properties, and only medical-grade sheepskins should be used (conditional recommendation, very low certainty of evidence based on Tiers 1, 2, 3A).
• Using a fiber support surface is suggested against if a pressure redistribution foam surface is available (conditional recommendation, very low certainty of evidence based on Tiers 1, 2, 3A).
• Routinely using an air fluidized full-body support surface is suggested for prevention. Still, it might be considered for very high-risk individuals or those with existing full-thickness injuries (conditional recommendation, very low certainty of evidence based on Tiers 1, 2, 3A).
• A low air loss (reactive) full body support surface could be used, especially when moisture and heat are contributing factors (conditional recommendation, very low certainty of evidence based on Tiers 1, 2, 3A).
• It is good practice to use a full-body support surface with pressure redistribution features for medical procedures and during transit.
• It is good practice to transfer individuals off spinal hard boards/backboards as soon as medically feasible.

Preventing Pressure Injuries in Seated Individuals

• It is good practice to consider individual needs when selecting a seat or wheelchair for pressure redistribution and shear reduction, including risk, mobility, body size, posture, and preferences.
• Using a seating support surface with pressure redistribution properties is strongly recommended for individuals at risk when seated (strong recommendation, moderate certainty of evidence based on Tiers 1, 2, 3A).
• Limiting the duration of sitting out of bed is suggested for individuals at risk who cannot reposition themselves (conditional recommendation, very low certainty of evidence based on Tiers 1, 2, 3A).
• It is good practice to frequently reposition seated individuals and encourage independent users to perform pressure redistribution maneuvers.
• It is good practice to position seated individuals to reduce pressure, shear, and friction, including selecting supportive chairs, reclining positions with elevated legs, and using dynamic weight shifting.

Preventing Heel Pressure Injuries

• It is good practice to elevate the heels so they are not in contact with the support surface.
• Using an appropriate heel offloading device is suggested (conditional recommendation, very low certainty of evidence based on Tiers 1, 2, 3A).
• It is good practice to use standard pillows or cushions to elevate heels if a specific offloading device is unavailable or inappropriate.
• No recommendation is made regarding the use of leave-on topical products for prevention due to extremely low confidence in effect estimates.
• A preventive dressing could be used as an adjunct to heel elevation and repositioning (conditional recommendation, low certainty of evidence based on Tiers 1, 2, 3A).
• If a preventive dressing is used for heels, a soft silicone adhesive multilayered foam dressing is suggested (conditional recommendation, very low certainty of evidence based on Tiers 1, 2, 3A).

The International Guideline is a collaborative effort by the National Pressure Injury Advisory Panel (NPIAP), European Pressure Ulcer Advisory Panel (EPUAP), and Pan Pacific Pressure Injury Alliance (PPPIA). The fourth edition, launched on February 27, 2025, is a “living guideline” with ongoing additions and updates based on the latest research, using the GRADE process for rigorous analysis and strength of recommendation.