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Pressure Injury/Pressure Ulcer: Learn the TNT Acronym

Pressure injuries in the U.S. are common and costly, affecting an estimated three million people per year and generating expenses of close to $11 billion (Raetz & Wick, 2015). Pressure injuries occur most often in acute care hospitals, nursing facilities, and home care settings (Agency for Healthcare Research and Quality [AHRQ], 2013).

The good news is that pressure injuries can be prevented! The first step in the prevention of pressure injuries is identifying individuals who are at risk. Some people have greater risk for developing pressure injuries than others.

One of the biggest risk factors is decreased or impaired mobility. Any individual who sits or lies in one position for an extended period is at risk for developing a pressure injury.

Many conditions can result in decreased or impaired mobility such as Parkinson’s disease, obesity, arthritis, and heart and lung diseases. Persons with altered mental status, such as those with dementia, may also have decreased or impaired mobility.

As a member of the healthcare team, you play an important role in the prevention of pressure injuries. It is important that you know what pressure injuries are, where they are most likely to occur, characteristics that increase pressure injury risk, and interventions that can reduce this risk.

What’s in a Name?

A pressure injury is soft tissue damage that occurs as a result of unrelieved force on a localized area of skin and underlying tissue, causing a reduction in blood supply and subsequently, cell death. Pressure injuries were previously called pressure ulcers (National Pressure Ulcer Advisory Panel [NPUAP], 2017).

How Does Injury Occur?

There are two types of “unrelieved forces” that can cause pressure injuries. The first type of force is pressure to the skin.


Pressure is created when there is skin-to-skin contact. For example, a person who is in a side-lying position will have skin-to-skin contact between the knees. Pressure is also created when a bony part of the body, called a “bony prominence”, presses against a hard surface. This traps the skin and underlying soft tissue between the two surfaces, causing damage. For example, when someone is lying on their back in bed, pressure is exerted on the bony prominences of the shoulder blades, hips, elbows, back of the head, and heels.

Medical devices against the skin can also cause pressure, resulting in damage. This type of damage is called a medical device-related pressure injury. The injury usually looks like the device itself, meaning the pattern or shape of the injury matches the device’s placement on the skin surface. An example of this is an injury on a wrist from a splint that is secured tightly, on the top of the nose where the CPAP mask presses over the bone, or on the tops of the ears from oxygen tubing.


The second type of “unrelieved force” that can cause pressure injuries is shear. Shear occurs when layers of skin and tissue are shifted against one another under pressure. For example, pulling someone toward the head of the bed without lifting their shoulders or buttocks away from the mattress results in friction and causes tissue injury.

Sometimes, the combination of both pressure and shear causes pressure injury.


Pressure Injury Sites

Pressure points are more common on areas of the body where bony prominences are most likely to put pressure on the skin when pressed against another surface. While pressure injuries are not limited to certain sites, there are common places on the body where pressure injuries form. These sites include the:

  • Elbows
  • Heels
  • Ankles
  • Inner knees
  • Hips
  • Buttocks
  • Coccyx, commonly called the tailbone
  • Lower back
  • Shoulders and shoulder blades
  • Back of the head
  • Ears


There are many things you can do in your daily practice to minimize the risk of pressure injury development. One approach is to think of “blasting away” pressure injuries with T-N-T. Each letter in T-N-T emphasizes an element associated with pressure injury prevention. When these three principles are collectively applied to a person’s care, you can significantly reduce a person’s risk for developing pressure injuries and other skin problems.

T: Turning

The first element involved in preventing pressure injuries is turning or repositioning. By repositioning someone, you shift the body’s pressure points and allow blood flow to return to areas on which they were lying. People with limited mobility should be repositioned at least every one to two hours while in bed and hourly when in a chair or wheelchair. Keep in mind that some people with delicate conditions require more frequent repositioning. You should always refer to a person’s care plan to determine their repositioning schedule.

N: Nutrition

The next element that is essential in preventing pressure injuries is achieving and maintaining proper nutrition. A well-balanced diet that provides adequate amounts of protein and fluids is necessary to prevent pressure injuries. The dietician plays a very important role in planning, and you should always refer to the dietary guidelines on the care plan. Provide fluids as often as possible when there are no fluid restrictions. Be proactive in monitoring the intake of both food and fluids, follow the individual’s care plan closely, and report any changes in their intake patterns and ability.

T: Toileting

The third essential element involved in preventing pressure injuries is toileting. People with incontinence are at great risk for developing pressure injuries. Many people who have problems with incontinence wear adult briefs and may not feel wetness in the brief. Wet skin is at risk for breakdown, so it is important to change wet pads and adult briefs immediately and to practice excellent skin hygiene.


Other Interventions

In addition to turning, nutrition, and toileting, there are some other measures you can take to prevent pressure injuries. Pressure relief, proper skin care, and physical activity are also important factors to consider.

Pressure injuries are painful and can lead to many complications like infection and even death! As a member of the healthcare team, you play an important role in the prevention of such devastation. You spend the majority of your time with the people receiving care and know them best. It is your responsibility as a member of the healthcare team to know what pressure injuries are, how they develop, where they are most likely to occur, what characteristics increase risk, and what interventions can reduce that risk and prevent injury.

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