Wheelchair users are at extremely high risk for pressure injuries — particularly over the sacrum, ischial tuberosities (sitting bones), and heels. Pressure injury prevention is one of the most important responsibilities you have for clients who spend significant time in a wheelchair.
Why Wheelchair Users Are High Risk
- Sustained pressure: Sitting in the same position for hours concentrates pressure over the same bony areas continuously — unlike walking, which constantly shifts load.
- Reduced sensation: Many wheelchair users (spinal cord injury, stroke, diabetic neuropathy) have reduced sensation and cannot feel the discomfort that prompts position shifting in people without impairment.
- Shear force: Sliding forward in the chair creates shear — a horizontal force that stretches and damages tissue even without direct compression.
- Moisture: Incontinence, sweating, and wound drainage create a moist environment that dramatically increases skin breakdown risk.
The Primary Pressure Points in a Wheelchair
Highest risk areas
- Ischial tuberosities (sitting bones)
- Sacrum/coccyx
- Back of thighs (from seat edge)
- Heels (if resting on footrests unsupported)
- Sides of ankles (from footrest contact)
Contributing factors
- Sliding forward in chair
- No pressure relief cushion
- Incorrect footrest height
- Extended sitting without relief
- Moisture at contact areas
Pressure Relief Techniques
Scheduled repositioning
For clients who cannot perform independent pressure relief, reposition or tilt every 15–30 minutes when in the wheelchair (more frequent than in bed due to higher sustained pressure over smaller areas). Follow the prescribed schedule in the care plan.
Weight shifts
If the client has any upper extremity strength: teach and encourage wheelchair push-ups (lifting buttocks off seat by pushing on armrests) or forward leans every 15–30 minutes. 30 seconds of relief significantly reduces pressure injury risk.
Pressure relief cushion
Any client sitting for more than 2 hours should have a prescribed pressure relief cushion — gel, air, or foam with appropriate properties. A flat sling-seat wheelchair with no cushion causes pressure injuries in hours for high-risk clients.
Transfer to bed or recliner
For extended rest periods, transfer the client out of the wheelchair and onto a bed or pressure-relieving surface. Remaining in the wheelchair for meals, activities, AND rest periods is insufficient pressure relief.
Skin Inspection in Wheelchair Users
- Lift or tilt to inspect the sacrum and sitting bones
- Check heels and ankles at footrest contact points
- Look for: redness that doesn't blanch, warmth, swelling, or skin changes
- Ask the client if they have any pain or unusual sensation in these areas
Moisture Management
- Check for and address incontinence promptly — do not allow a client to sit in wet clothing
- Moisture barrier creams on at-risk areas protect the skin surface from moisture damage
- Keep the seating surface dry — moisture on the cushion accelerates skin breakdown
- Report new or increasing incontinence to the nurse — it is both a dignity concern and a serious skin risk