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Am Fam Physician. 2023;108(2):166-174

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Pressure injuries are localized damage to skin or soft tissue. They commonly occur over bony prominences and often present as an intact or open wound. Pressure injuries are common and costly, and they significantly impact patient quality of life. Comprehensive skin assessments are crucial for evaluating pressure injuries. Staging of pressure injuries should follow the updated staging system of the National Pressure Injury Advisory Panel. Risk assessments allow for appropriate prevention and care planning, and physicians should use a structured, repeatable approach. Prevention of pressure injuries focuses on assessing and optimizing nutritional status, repositioning the patient, and providing appropriate support surfaces. Treatment involves pressure off-loading, nutritional optimization, appropriate bandage selection, and wound site management. Pressure injuries and surrounding areas should be cleaned, with additional debridement of devitalized tissue and biofilm if necessary. All injuries should be monitored for local infection, biofilms, and osteomyelitis. Appropriate wound dressings should be selected based on injury stage and the quality and volume of exudate.

Pressure injuries are focal damage to skin, underlying tissue, or mucous membranes resulting from pressure that is intense, prolonged, or both. The combination of pressure and shear forces can also cause pressure injuries.1 Bony prominences are common sites for pressure injuries. These injuries can also be related to medical devices or other objects that come in contact with the patient's skin. The term pressure injury is recommended, although these injuries are also known as pressure ulcers, decubitus ulcers, pressure sores, or bed sores.13


More than 3 million pressure injuries are treated in the United States each year.4,5 Stage 1 and 2 pressure injuries are most prevalent.6 Longitudinal studies have shown a decline in the incidence of pressure injuries over the past two decades, which could be related to increased clinical attention or changes in definitions or populations.7 Hospital-associated pressure injuries are estimated to cost the U.S. health care system $26.8 billion annually, with costs disproportionately associated with more advanced stages of injury.8


Staging of a pressure injury should use the updated National Pressure Injury Advisory Panel (NPIAP) staging system (Figure 1).9 Notable changes from previous iterations include limiting the use of the term ulcer to only injuries featuring breaks in the skin and expanding injury types to include those caused by medical or other devices.3 Medical device–related pressure injuries result from a device in direct contact with a patient. It is important to consider the contributory device, but the injury should also be defined by the staging system.1 Pressure injuries can occur on mucosal linings of the gastrointestinal, respiratory, or genitourinary tracts. Due to the locations of these injuries, they cannot be staged.3

Risk Assessment

Assessing for risk factors is crucial to ensure appropriate prevention and plan of care. National Institute for Health and Care Excellence guidelines and those developed jointly by the European Pressure Ulcer Advisory Panel (EPUAP), NPIAP, and Pan Pacific Pressure Injury Alliance (PPPIA) recommend a comprehensive clinical assessment for any risk factors central to the pathophysiology of pressure injury development, such as sensory loss, malnutrition, inactivity, immobility, and reduced perfusion.1,10

The risk assessment should focus on factors that influence the magnitude, type, and duration of pressure, as well as patient-specific factors that impact individual tolerance and susceptibility to injury 1,11 (Table 11,12,13). Reduced activity (ability to complete activities of daily living) and mobility (ability to change or control physical position) increase mechanical load and are consistently associated with the development of pressure injuries.1,12

 Neonates and children (because of limited mobility, lack of skin maturity, relatively larger skin surface area and larger head circumference, and higher risk of nutritional deficiencies)
 Older adults
Increased body temperature
Limited mobility
 In hospice or palliative care
 Increased immobilization perioperatively
 Progressive neurologic conditions (multiple sclerosis, Parkinson disease)
 Spinal cord injury
Medical comorbidities
 Congestive heart failure
 Dementia (e.g., vascular, Alzheimer)
 Diabetes mellitus
 Peripheral vascular disease
Medical device or prosthesis use
 Bowel or bladder incontinence
 Increased perspiration
 Wound drainage
Personal history of pressure injuries or current Stage 1 pressure injury
Poor nutrition or malnutrition
Prolonged stay at a nursing home or rehabilitation facility

Preexisting pressure injuries, diabetes mellitus, vascular disease, and impaired circulation can further increase risk. Increased moisture from urine, stool, and sweat can cause skin maceration and escalate the risk of pressure injuries. The patient's external environment, such as hard surfaces on prostheses, shear forces from wheelchair use, or uneven sleeping surfaces, can further compound risk.

Particular attention should be placed on populations at higher risk of pressure injuries, including people who are critically ill; individuals with spinal cord injuries or other immobility conditions; people receiving palliative care; acutely ill and immobilized neonates and children; people with obesity; people in the preoperative period; and people in the community receiving care for advanced age or requiring facility rehabilitation services due to mobility limitations.1,10,14,15

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