The Big Picture
A pressure injury develops when pressure reduces the blood supply to an area of the body. These injuries often happen over areas where bone lies close to the skin.
Pressure injuries develop over time. The longer pressure stays on the skin, the greater the risk of injury. Preventing them includes relieving pressure, protecting the skin, keeping the skin clean and dry, and following the client’s care plan.
A CCA needs to check the client’s skin during personal care and report signs of a pressure injury right away.
Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.
Quick tip: Tap, click, or press Enter on any term with a dotted underline and an ⓘ icon to see its plain-English definition.
Start Here If You’re Overwhelmed
Focus on these core ideas:
- A pressure injury is an injury caused by pressure that is not relieved.
- Pressure points are bony areas that bear body weight in certain positions.
- Pressure, friction, and shearing are important causes of skin breakdown and pressure injuries.
- Early signs include pale or greyed skin or a warm, reddened area. Pain, burning, itching, or tingling can also occur.
- Follow the care plan for repositioning, positioning, skin care, and protective equipment.
- Report signs of skin breakdown or pressure injury at once and record observations according to employer policy.
Jump to:
Course Notes: Key Ideas You Need to Know
What Is a Pressure Injury?
A pressure injury is an injury caused by pressure that is not relieved. Other names include decubitus ulcer, bedsore, pressure ulcer, and pressure sore.
Pressure injuries often occur over a bony prominence. This is an area where the bone seems to stick out beneath the skin.
Common bony prominences include:
- shoulder blades
- elbows
- hip bones
- sacrum, the bone in the lower part of the spine
- knees
- ankle bones
- heels
- toes
These areas become pressure points when they bear the body’s weight in certain positions.
Pressure from body weight can reduce blood flow to the area. Without enough blood flow, cells do not receive enough oxygen and nutrients. Continued pressure can cause skin and underlying tissues to die.
Moisture from perspiration or body excretions increases the risk around pressure points. Infection can also develop and become difficult to treat.
What Causes Pressure Injuries?
Pressure, friction, and shearing are common causes of skin breakdown and pressure injuries.
Other contributing factors include:
- breaks in the skin
- poor circulation to an area
- moisture from sources such as perspiration or urine
- dry, flaky skin
- irritation from urine and stool
Pressure
Pressure occurs when skin over a bony area becomes squeezed between the bone and another hard surface, such as a mattress or chair seat.
Pressure interferes with blood flow to the skin and tissues underneath.
Pressure injuries can also develop when body areas press or rub against each other. In an obese client, skin-to-skin friction can cause injury. In a very thin client, two bony areas such as the knees or ankles can come into direct contact.
Friction
Friction happens when skin rubs against another surface.
Friction can scrape the skin and create a wound. The opening can provide a way for microbes to enter. Healing requires a good blood supply and prevention of infection.
Poor blood flow or infection can contribute to a pressure injury.
Shearing
Shearing happens when the skin stays against a surface while deeper tissues move downward. This movement tears skin tissue and places pressure on the skin.
Proper lifting, positioning, transferring, and repositioning help prevent friction and shearing.
The Braden Scale
The Braden Scale is used in many health care settings to predict the likelihood that a client will develop a pressure injury.
It considers:
- sensory function
- skin moisture
- activity level
- nutrition
- likelihood of friction and shear during movement
Other Areas at Risk
Skin folds also need careful attention. Areas at risk include:
- under the breasts
- between abdominal folds
- folds on the legs and buttocks
- between the toes
These areas can stay warm and moist because of perspiration and limited exposure to air. Moisture can increase the risk of infection, which can contribute to pressure sores.
Some body lotions add moisture to these areas and increase the risk of infection.
CCA action: Wash skin-fold areas well and dry them thoroughly.
Report: Tell your supervisor about redness or skin irritation.
A small piece of cloth or gauze under a large breast can help reduce moisture and friction when a bra is not worn.
Some nurses apply barrier cream to washed and dried skin folds. Consult your supervisor or the client before trying this cream on a client.
Who Is at Greater Risk?
Clients face a greater risk of pressure injuries when they:
- must remain in a bed or chair
- need moderate to complete help with moving
- have loss of bowel or bladder control
- have poor nutrition
- have altered mental awareness
- have difficulty sensing pain or pressure
- have circulatory problems
- are older
- are obese or very thin
Early Signs to Watch For
The first sign of a pressure injury can be:
- pale or greyed skin
- a warm, reddened area
Skin colour changes can be harder to notice in clients with dark skin.
A client might report:
- pain
- burning
- itching
- tingling
These symptoms can indicate poor blood flow to the area and should be reported to the supervisor.
Some clients do not feel anything unusual. Skin observation remains important even when the client reports no discomfort.
CCA action: Check the client’s skin every time you provide personal care.
Report: Immediately notify your supervisor when you observe signs of a pressure injury.
The Four Stages of Pressure Injuries
Stage 1
The skin is redder than the surrounding skin. The colour does not return to its natural colour after pressure is removed.
Report: This finding must be reported promptly to the nurse or supervisor.
Stage 2
The skin cracks, blisters, or peels. A shallow crater can also be present.
Stage 3
The skin is gone. Underlying tissues are exposed and damaged.
Drainage can occur.
Stage 4
Muscle and bone are exposed and damaged.
Drainage is likely.
Nova Scotia CCA Note
Sorrentino’s Canadian Textbook for the Support Worker, 5th Edition teaches four numbered stages of pressure injuries. Current Nova Scotia long-term care reporting also recognizes unstageable and deep tissue pressure injuries alongside Stage 2, Stage 3, and Stage 4 pressure injuries. This means the four stages remain important study terms, but they are not the only classification terms used in current Nova Scotia long-term care reporting. (novascotia.ca)
Why this matters in Nova Scotia: You should recognize the four stages from Sorrentino while also recognizing the additional terms used in current provincial long-term care reporting.
Official source: Pressure injuries in long-term care: public reporting
Last checked: September 14, 2026
Why Prevention Matters
Pressure injuries develop over time. The longer pressure remains on the skin, the greater the risk of injury.
Prevention is easier than healing an established pressure injury.
Prevention includes:
- frequent position changes
- proper diet with plenty of fluid
- cleanliness
- good skin care
- preventive measures listed in the care plan
Repositioning and Positioning
Always follow the repositioning schedule in the client’s care plan .
Some clients need repositioning at least every 2 hours. Others need repositioning every 15 minutes. The care plan gives the instructions for the individual client.
Position the client according to the care plan. Use pillows for support as directed by your supervisor.
A 30-degree lateral position is recommended.
Use proper lifting, positioning, and transferring procedures to reduce friction and shearing.
Safety: To reduce shearing, do not raise the head of the bed above 30 degrees. Always follow the client’s care plan.
Skin Care and Moisture Control
Keep the client’s skin clean and dry after bathing.
Keep the skin free from moisture caused by:
- urine
- stool
- perspiration
- wound drainage
Check clients with loss of bowel or bladder control frequently. Also check clients who perspire heavily or have wound drainage.
Dry carefully between the toes and between skin folds.
Change clothing and linens when needed.
Check with your supervisor before using soap on a client because soap can dry and irritate the skin.
Apply moisturizer to dry areas as directed, including:
- hands
- elbows
- legs
- ankles
- heels
Do not apply moisturizer under the breasts, between skin folds, or between the toes. Your supervisor will tell you which product to use and where to apply it.
Protect the Skin From Friction and Irritation
Keep linens clean, dry, and free of wrinkles.
Avoid scratching, scrubbing, or rubbing the client’s skin during bathing or drying.
Use pillows and blankets to prevent skin-to-skin contact and reduce moisture and friction.
Give a back massage after repositioning the client.
Avoid: Do not massage bony areas or pressure points.
Never rub or massage a reddened area. Massage the skin around the reddened area instead.
Protect the Heels and Other Pressure Points
Keep the client’s heels off the bed.
Use pillows or other devices as directed. Place them under the lower legs from the middle of the calf to the ankle.
Use protective devices according to instructions from the supervisor and the care plan.
Clients sitting in chairs should be reminded to shift position every 15 minutes to reduce pressure on bony points. Assist when requested.
Areas where a client had a pressure injury in the past remain at risk even after healing. Pay close attention to these areas and continue following pressure-injury prevention guidelines.
Reporting and Recording
Report: Report signs of skin breakdown or pressure injury at once.
Document: Record your observations according to employer policy.
Nova Scotia CCA Note
Sorrentino tells the CCA to observe the skin, report signs of pressure injury, and follow the care plan. In Nova Scotia, the current Continuing Care Assistant Occupational Standards of Practice describe this more specifically as an observational point of care assessment. A CCA makes ongoing observations before, during, and after care. Skin integrity is one of the areas included, and changes that need attention are escalated to a supervisor in alignment with the care plan. (novascotiacca.ca)
This observational assessment is not a nursing assessment. A Nova Scotia CCA does not complete the comprehensive evaluation used to analyze information and make care-planning decisions. The CCA observes, recognizes changes that require escalation, applies the care plan, and documents according to employer documentation guidelines. (novascotiacca.ca)
Why this matters in Nova Scotia: You need to separate the CCA’s role in observing and escalating skin changes from the broader assessment and care-planning role of regulated health professionals.
Official source: Continuing Care Assistant Occupational Standards of Practice
Last checked: September 14, 2026
Pressure-Reducing Surfaces
Clients at risk for pressure injuries can be placed on surfaces designed to reduce or relieve pressure.
Examples include:
- foam mattresses
- air mattresses
- alternating-air mattresses
- gel mattresses
- water mattresses
The health care team decides which surface is best for the client.
Treatment and the CCA Role
A physician orders specific treatment for a pressure injury.
Orders can include:
- wound-care products
- medications
- treatments
- special equipment
Your supervisor and the care plan tell you what you need to do.
Do not choose the pressure-relieving surface or pressure-injury treatment yourself. Follow the directions given for the individual client.
Special Beds
Some special mattresses use air, gel-like material, or special foam. These surfaces distribute body weight more evenly and reduce pressure on bony areas.
Some special beds reposition the client without requiring the worker to move the client manually. Depending on the bed, it can:
- turn the client to a prone or supine position
- tilt the entire bed from side to side
- rotate continually from side to side
These beds change the pressure points while keeping body alignment unchanged. They also reduce friction. Beds that continually rotate can be used for clients with spinal cord injuries.
If you care for a client using a special bed, ask which bedding the mattress requires.
Some special mattresses require that incontinence or transfer pads not be placed under the client because the extra padding reduces the mattress’s effectiveness.
For other mattresses, the bottom sheet is recommended not to be tucked underneath.
Bed Cradles
A bed cradle, also called an Anderson frame, is a metal frame placed over the client on the bed.
Top sheets go over the frame so the sheets do not place pressure on the client’s legs and feet.
If the client feels too warm, the top sheets can be folded back to expose the feet. If the client prefers them in place, they can be tucked at the bottom of the mattress and mitered.
The sheets can also be tucked under both sides of the mattress to protect the client from drafts and chilling.
In home care, a sturdy cardboard box can serve as a bed cradle. The supervisor gives instructions for lining the box so it does not place pressure on the heels.
Elbow Protectors
Elbow protectors reduce friction between the elbow and the bed.
They can be made from foam rubber or sheepskin. They fit around the elbow, and some have straps to hold them in place.
Heel Elevators
Pillows or special cushions can raise the heels away from the bed.
Special braces and splints can also keep pressure off the heels.
Flotation Pads
Flotation pads or cushions contain a gel-like substance inside a heavy plastic outer case.
They can be used on chairs and wheelchairs to reduce pressure while the client sits.
Place the pad inside a pillowcase or special cover so the plastic does not touch the client’s skin.
Egg Crate-Like Mattresses
An egg crate-like mattress is a foam pad with raised peaks that distribute the client’s weight.
It sits on top of a regular mattress and uses a special cover to protect it from moisture and soiling. Only a bottom sheet covers it.
Many agencies do not use these mattresses because they can aggravate pressure points. The foam is also flammable and can create a fire hazard.
Some family physicians still recommend these mattresses for home use.
Clients should never smoke in bed. The danger is especially important when a flammable mattress pad is in use.
Other Pressure-Injury Equipment
Trochanter rolls and footboards can also be used to help prevent pressure injuries.
Exam Clue Words
- Follow the care plan: Repositioning schedules, positioning, protective devices, and preventive measures must follow the individual client’s directions.
- Do not: Do not raise the head of the bed above 30 degrees when reducing shearing, and do not massage bony areas or pressure points.
- Never: Never rub or massage a reddened area.
- Report: Report signs of skin breakdown or pressure injury at once. Stage 1 changes must be reported promptly to the nurse or supervisor.
- Record: Record your observations according to employer policy.
Common Mix-Ups
| Wrong Idea | Better Idea |
|---|---|
| Friction and shearing mean the same thing. | Friction involves skin rubbing against a surface. Shearing involves skin staying against a surface while deeper tissues move. |
| Moisturizer belongs on every dry-looking area. | Moisturizer is used on directed dry areas, but not under breasts, between skin folds, or between toes. |
| The CCA chooses the pressure-relieving surface or treatment. | The health care team chooses the pressure-relieving surface, a physician orders specific treatment, and the CCA follows the supervisor’s directions and care plan. |
Fast Review
Pressure-injury questions often depend on recognizing risk, early signs, stages, prevention rules, and care-plan directions. Keep the specific numbers and reporting rules clear.
- A pressure injury results from pressure that is not relieved.
- Common pressure points include the shoulder blades, elbows, hips, sacrum, knees, ankles, heels, and toes.
- Pressure reduces blood flow and can damage or destroy skin and underlying tissues.
- Pressure, friction, and shearing are major causes of skin breakdown and pressure injuries.
- Clients who cannot move easily, have poor nutrition or circulation, lose bowel or bladder control, have altered awareness, or cannot sense pain or pressure face greater risk.
- Early signs include pale or greyed skin or a warm, reddened area. Pain, burning, itching, and tingling can also occur.
- Stage 1 has persistent redness. Stage 2 involves cracking, blistering, peeling, or a shallow crater. Stage 3 exposes damaged underlying tissue. Stage 4 exposes damaged muscle and bone.
- Check the client’s skin every time you provide personal care and report signs of a pressure injury immediately.
- Some clients need repositioning at least every 2 hours, while others need it every 15 minutes. Follow the individual care plan.
- Do not raise the head of the bed above 30 degrees when reducing shearing. A 30-degree lateral position is recommended.
- Keep skin clean and dry, reduce friction and moisture, keep heels off the bed, and never rub or massage reddened areas.
- Report skin breakdown or pressure injuries at once and record observations according to employer policy.
Final Pep Talk
There are a lot of details in this topic, so focus first on the four stages, the prevention numbers, and what must be reported. Once you separate pressure, friction, and shearing and connect each rule to the care plan, the rest becomes easier to organize.