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Learning Objectives

  • Identify the four pathophysiologic factors of pressure injury (PI) development.

  • Describe the six PI classifications according to the National Pressure Injury Advisory Panel’s (NPIAP’s) guidelines.

  • Outline the process for PI risk screening and risk assessment.

  • Describe the essential strategies for a successful PI prevention program.

  • Describe the standard of care for treatment of full-thickness PI.

Key Clinical Points

  1. Pressure injuries are caused by mechanical force compressing tissues between the bony skeleton and external surfaces directly damaging the cell wall leading to cellular death. Ischemia from occluded capillaries and lymphatics and release of oxygen free radicals from reperfusion injury contribute to the extent of the injury.

  2. Prevention includes screening for risk followed by risk assessment using standardized risk assessment tools to determine individual-specific risk and implementing targeted prevention interventions based on identified risk factors.

  3. Scheduled repositioning programs, use of reactive and active support surfaces, assessment and management of nutrition, and use of prophylactic dressings are key prevention strategies.

  4. Adequate, timely, and complete debridement of necrotic tissue, identification and treatment of infection and management of biofilm development, and providing a moist wound environment are the key tenets of appropriate pressure injury care.

  5. Medical record documentation must include pressure injury risk status, prevention strategies, pressure injury assessment (size, stage, location, and description of wound bed minimally), treatment plan, and evaluation of treatment success.

  6. Partial-thickness pressure injuries (stage 2) should heal within 60 days maximum; full-thickness pressure injuries (stage 3/4/unstageable) should demonstrate improvement in overall injury status every 2 to 4 weeks.


As recently as 2014, pressure injury (PI) among older adults has been called a global “public health problem.” This conclusion was reached based on the high rates of PI among nursing home residents as well as hospitalized patients.


A PI is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open injury and may be painful. The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear. According to the National Pressure Injury Advisory Panel (NPIAP), the tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities, and condition of the soft tissue. The most common bony prominences are sacrum, heels, ischial tuberosities, trochanters, lateral malleoli, and heels. PI on the sacrum and heels are most common. However, PI can occur on any soft tissue exposed to pressure, so the clinician should not be guided only by the location of the wound to determine its etiology. Other terms for PI include pressure ulcer, bedsore or decubitus ulcer. The later terms imply development only in those confined to bed. Since the major causative factor is pressure, and because PI occurs in positions other than just lying down, ...

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