Prevention of pressure-induced skin and soft tissue injury
- 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 among the most common conditions encountered in hospitalized patients or those requiring long-term institutional care . Prevention is a cost-effective approach that positively impacts health status [2-6]. As of October 2008, guidelines from the Center for Medicare and Medicaid Services (CMS) in the United States state that hospitals will no longer receive additional payments when patients develop stage 3 or 4 pressure induced injuries (table 1) . Failure to provide appropriate prevention and care may also expose providers to liability .
The prevention of pressure-induced skin and soft tissue injuries will be reviewed here. The treatment, epidemiology, pathogenesis, clinical manifestations, and staging are discussed separately. (See "Epidemiology, pathogenesis, and risk assessment of pressure ulcers" 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.
Risk assessment, which includes a comprehensive history and physical examination, should identify patients at risk for pressure-induced skin and soft tissue injuries who will benefit from preventive measures as well as factors that are potentially correctable . The pathogenesis, risk factors, and risk prediction tools for pressure-induced skin and soft tissue injuries are discussed in detail separately. (See "Epidemiology, pathogenesis, and risk assessment of pressure ulcers", section on 'Risk factors' and "Epidemiology, pathogenesis, and risk assessment of pressure ulcers", section on 'Risk prediction'.)
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- CLASSIFICATION AND TERMINOLOGY
- RISK ASSESSMENT
- PRESSURE REDISTRIBUTION
- Support surfaces
- Static positioning
- - Position and inclination
- - Repositioning
- - Repositioning interval
- Continuous rotation
- SUPPORTIVE INTERVENTIONS
- Improve mobility
- Improve skin perfusion
- Provide proper skin care
- - Minimize excess moisture
- Correct malnutrition
- QUALITY INITIATIVES
- PROVIDER EDUCATION AND STAFFING
- FAILURE OF PREVENTIVE MEASURES
- COST EFFECTIVENESS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS