When Is a Patient "Too Unstable" to Turn?
Preventing pressure injuries is a core nursing responsibility in the ICU. Evidence shows that infrequent repositioning (less than every 4 hours) significantly increases the risk of pressure injuries, even in high-risk patients (Tayyib & Coyer, 2016). Most ICU patients can safely tolerate frequent repositioning, and true instability requiring skipped turns is rare (Penoyer et al., 2019).
Use this guide to make evidence-based decisions, erring on the side of more frequent repositioning, and to maximize use of preventative tools.
  • True instability is rare and should be based on clear, objective criteria:
  • Life-threatening arrhythmias
  • Severe hypotension unresponsive to treatment after a trial turn (e.g., MAP <65 mmHg that does not recover within 10 minutes)
  • Active resuscitation or immediate life-threatening events (Penoyer et al., 2019)
  • Most patients on vasopressors, mechanical ventilation, or with mild hemodynamic fluctuations can and should still be repositioned with appropriate monitoring (Penoyer et al., 2019).
  • If unsure, attempt a gentle turn with close monitoring; if instability occurs and does not resolve, document and reassess at the next scheduled turn.
Pressure Injury Prevention Tools and How to Use Them
Summary: Takeaways
Err on the side of turning
Most ICU patients can tolerate frequent repositioning. If in doubt, try a gentle turn with monitoring.
Maximize preventative tools
Use sacral foams, heel offloading, and appropriate mattresses for all at-risk patients, not just those with existing injuries (Penoyer et al., 2019; Tayyib & Coyer, 2016; Latimer et al., 2024).
Minimize layers
More than two layers under the patient increases risk—keep bedding simple (Penoyer et al., 2019).
Document clearly
If a turn is skipped, document the specific, objective reason and reassess frequently.
Education and teamwork
Regularly review pressure injury prevention protocols and encourage a culture of proactive prevention (Alshahrani et al., 2021; Kandula, 2025).
References
Alshahrani, B., Sim, J., & Middleton, R. (2021). Nursing interventions for pressure injury prevention among critically ill patients: A systematic review.. Journal of clinical nursing. https://doi.org/10.1111/jocn.15709
Kandula, U. (2025). Impact of multifaceted interventions on pressure injury prevention: a systematic review. BMC Nursing, 24. https://doi.org/10.1186/s12912-024-02558-9
Latimer, S., Walker, R., Chaboyer, W., Thalib, L., Coyer, F., Deakin, J., & Gillespie, B. (2024). Prophylactic dressings to prevent sacral pressure injuries in adult patients admitted to intensive care units: A three-arm feasibility randomized controlled trial.. Intensive & critical care nursing, 84, 103746. https://doi.org/10.1016/j.iccn.2024.103746
Penoyer, D., Britt, C., Wilkinson, L., Arwood, L., & Sole, M. (2019). 687: A CRITICAL CARE-SPECIFIC PUP BUNDLE REDUCES HOSPITAL-ACQUIRED PRESSURE ULCERS IN THE ICU. Critical Care Medicine, 47, 324. https://doi.org/10.1097/01.ccm.0000551439.58530.5c
Shi, C., Dumville, J., & Cullum, N. (2018). Support surfaces for pressure ulcer prevention: A network meta-analysis. PLoS ONE, 13. https://doi.org/10.1371/journal.pone.0192707
Tayyib, N., & Coyer, F. (2016). Effectiveness of Pressure Ulcer Prevention Strategies for Adult Patients in Intensive Care Units: A Systematic Review.. Worldviews on evidence-based nursing, 13 6, 432-444. https://doi.org/10.1111/wvn.12177