Epidemiology, pathogenesis, and risk assessment of pressure ulcers
- Dan Berlowitz, MD, MPH
Dan Berlowitz, MD, MPH
- Boston University Schools of Public Health and Medicine
- Section Editors
- Kenneth E Schmader, MD
Kenneth E Schmader, MD
- Editor in Chief — Geriatric Medicine
- Section Editor — Geriatrics
- Chief, Division of Geriatrics
- Duke University
- Director, Geriatric Research Education and Clinical Center
- Durham VA Medical Centers
- Hilary Sanfey, MD
Hilary Sanfey, MD
- Section Editor — General Surgical Principles
- Professor of Surgery
- SIU School of Medicine
Pressure-induced skin and soft tissue injuries are lesions caused by unrelieved pressure that results in damage to the underlying tissue. Generally, these are the result of soft tissue compression between a bony prominence and an external surface for a prolonged period of time [1,2]. The consequences of pressure-induced skin and soft tissue injury range from nonblanchable erythema of intact skin to deep ulcers extending to the bone.
Pressure-induced injuries impose a significant burden not only on the patient but on the entire health care system. Reducing their frequency is an important component of current goals for patient safety, as evidenced by the Institute for Healthcare Improvement (IHI) 5 Million Lives Campaign and the decision by the United States Center for Medicare and Medicaid Services to not reimburse hospitals for the treatment of hospital-acquired pressure-related injuries [3-5].
Knowledge of factors contributing to the pathogenesis of pressure-induced skin and soft tissue injury allows the identification of patients at risk for ulcer development such that preventive measures may then be targeted to those specific patients. The epidemiology, pathogenesis, risk factors, and risk assessment of pressure ulcers will be reviewed here. Prevention and treatment are discussed separately. (See "Prevention of pressure-induced skin and soft tissue injury" and "Clinical staging and management of pressure-induced skin and soft tissue injury".)
CLASSIFICATION AND TERMINOLOGY
The National Pressure Ulcer Advisory Panel (NPUAP) made changes to their classification in April 2016 and suggested using the terminology "pressure injury" instead of "pressure ulcer" to describe these wounds. (See "Clinical staging and management of pressure-induced skin and soft tissue injury", section on 'NPUAP staging'.)
These changes were made to recognize the fact that lesser degrees of skin damage due to pressure may not be associated with skin ulceration (Stage 1) and that deep tissue injury can occur without overlying skin ulceration (suspected deep tissue injury) (table 1). However, their generalized term "pressure injury" does not address the many other types of injury that can result from pressure, such as rhabdomyolysis in an unconscious patient. Thus, we will use the term "pressure-induced skin and soft tissue injury" to encompass the broad range of ischemic damage that can be caused by prolonged pressure. The terms "pressure-induced skin injury" or "pressure-induced soft tissue (or deep tissue) injury" are used where specifically applicable. We use the term "pressure injury" when referring to the staging of a specific lesion as defined by the NPUAP classification (eg, unstageable pressure injury) or to replace the term "pressure ulcer" in studies published prior to this classification change that use "pressure ulcer" generically when the stage is not specified. We use the term "pressure ulcer" for the specific circumstance where the integrity of the skin surface is disrupted.
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