Pressure injury: prevention

EVIDENCE-
BASED CARE
SHEET

ICD-9
707.0

ICD-10
L89

Authors
Tanja Schub, BS

Cinahl Information Systems, Glendale, CA

Eliza Schub, RN, BSN
Cinahl Information Systems, Glendale, CA

Reviewers
Eva Beliveau, RN, MSN, CNE

Professor of Nursing, Northern Essex
Community College

Gina DeVesty, BSN, MLS
Cinahl Information Systems, Glendale, CA

Nursing Executive Practice Council
Glendale Adventist Medical Center,

Glendale, CA

Editor
Diane Hanson, MM, BSN, RN, FNAP

August 13, 2021

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2021, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Pressure Injuries: Prevention Strategies

What We Know
› Pressure injuries (PIs ; Figure 1 )—referred to as “pressure ulcers” until the change in

terminology by the National Pressure Ulcer Advisory Panel (NPUAP; 2016) and also
referred to as decubitus ulcers, pressure sores, or bedsores—are localized, oftentimes
painful, areas of damaged skin and/or underlying soft tissue resulting from prolonged or
intense pressure or a combination of pressure and shear. The skin at the site of a PI can be
intact or the injury can appear as an open ulcer. PIs usually occur over bony prominences
or in areas where medical or other devices or surfaces exert prolonged pressure against
the skin. Factors that can potentiate the injurious effects of pressure and shear include
prolonged skin moisture, poor nutrition, and poor perfusion.(11) (For details, see Quick
Lesson About … Pressure Injuries: an Overview )

Figure 1: Graphic illustrating four of the eight pressure injury classifications
established by the National Pressure Ulcer Advisory Panel (NPUAP).

Additional categories include Unstageable, Deep Tissue, Medical
Device Related, and Mucosal Membrane Pressure Injury. Copyright©

Nanoxyde, 2008. Licensed under Creative Commons Attribution-Share
Alike 3.0 Unported, 2.5 Generic, 2.0 Generic and 1.0 Generic License

• Of note, the majority of current literature does not yet reflect the NPUAP’s recent
change in terminology; it is expected that the termpressure injury will gradually replace
pressure ulcer anduse of Arabic numerals to identify PIs stagesinstead of Roman
numeral,as acknowledgement of the change becomes widespread(1)

–The European Pressure Ulcer Advisory Panel (EPUAP) continues to support the
guidelines issued in 2014 and has not yet adopted the new terminology and pressure
ulcer classification system propounded by NPUAP in April 2016(8)

• PI risk factors include older age, impaired mobility, physical inactivity, being subject
to friction and shear, moisture, low body mass index (BMI) and/or poor nutritional
status (especially low protein intake), dehydration, incontinence, sensory loss, cognitive
impairment, certain medical conditions (e.g., diabetes mellitus, [DM] peripheral vascular

disease [PVD], stroke, and spinal cord injury [SCI]), drugs that affect wound healing
(e.g., corticosteroids), hip fracture, smoking, and need for assisted ventilation(4,5,6,10,14)

• PIs are associated with a decrease in quality of life and a 1-yearmortality rate that approaches40%(14)

• Up to 95% of PIs are thought to be preventable(15)

–As of 2008, the Centers for Medicare & Medicaid Services (CMS) in the United States no longer reimburses facilities for
treatment of facility-acquired Stage 3 and 4 PIs(2)

› Standard prevention strategies include risk assessment using standardized PI risk assessment tools (e.g., Braden scale), skin
care, frequently redistributing pressure (particularly over bony prominences) by frequent repositioning, maintaining good
hygiene, minimizing moisture (especially that caused by incontinence), management of incontinence by scheduled toileting
plans, use of mattresses and/or cushions to reduce/relieve pressure, preventing skin damage through use of topical agents
(e.g., creams, ointments) or dressings, avoiding over-sedation, and optimizing nutrition(4,5,6,9,10,14,15)

• PI risk assessment scales have low to modest predictive ability and Cochrane reviewers found no reliable evidence
demonstrating that the use of structured risk assessment tools reduces the incidence of PIs(13)

• Although the value of regular patient repositioning in reducing the risk of developing PIs has been confirmed, and clinical
practice guidelines commonly recommend patient repositioning every 2 hours, the optimal frequency for repositioning has
not been established in clinical trials(6)

• Cochrane reviewers analyzed 59 randomized trials and found evidence that(9)

–constant low-pressure support surfaces reduce the incidence of PIs compared to standard foam mattresses
–sheepskin mattress overlays reduce the incidence of PIs
–pressure-relieving overlays on the operating table reduce the incidence of PIs
–alternating pressure mattresses reduce the incidence of PIs compared to standard foam mattresses
–alternating pressure mattresses and constant low-pressuresupport surfaces have similar efficacy for reduction of PIs
–alternating pressure mattresses and alternating pressure overlays have similar efficacy for reduction of PIs
–addition of a Jay Gel cushion to foam wheelchair cushions reduces PI risk

• Cochrane reviewers of256 recent studies for the prevention and treatment of PI report the focus on repositioning, nutrition,
and support surfaces continue to be major recommendations(13)

• Although malnutrition is associated with increased PI risk, there is insufficient evidence to support the routine use of
vitamin C and zinc supplementation to reduce PI risk(6)

• Authors of a recent systematic review found no evidence supporting the use of any behavioral or educational interventions
for PI prevention in adults with SCI(3)

–Researchers in South Korea randomized 47 patients with SCI to a self-efficacy enhancement program or a control group.
Patients in the intervention group had greater improvements in self-care knowledge, self-efficacy, and self-carebehaviors
for PI prevention. However, there was no significant difference in incidence of PIs between the groups(7)

› The prevalence of PIs in U.S. facilities has declined over the last decade(12)

• Researchers who conducted the International Pressure Ulcer Prevalence Survey, a 10-year study of 918,621 inpatients
in the U.S., observed that the overall prevalence of PIs declined from 13.5% in 2006 to 9.3% in 2015. The prevalence of
facility-acquired PIs declined from 6.2% in 2006 to 3.1–3.4% in 2013–2015(12)

What We Can Do
› Learn more about PI prevention so you can accurately assess your patients’ personal characteristics and health education

needs; share this knowledge with your colleagues(5)

› Collaborate with an interdisciplinary healthcare team at your facility to develop a PI prevention plan to reduce the risk for PI
development

› Assess PI risk and skin condition(6,14)

• On admission, assess for skin compromise, especially at bony prominences; signs of recent trauma; effects of friction or
shear; immobility and/or functional incapacity; factors that influence healing (e.g., nutritional status); and incontinence.
Ask about medical history (including previous treatments or surgeries); and measure body weight(6)

• Reassess risk daily in acute care settings, at each home care visit, and weekly in long-term care settings

–Use a valid risk assessment scale (e.g., Braden Scale for Predicting PI Risk; the most widely used risk assessment tool
according to facility protocol(6,14)

– Risk assessment tools permit routine organized assessment of the skin and factors related to skin integrity
› Optimize nutrition and hydration(6)

• Request referral to a registered dietitian for patient evaluation and recommendation of specific amounts of proteins,
calories, fluids, electrolytes, and micronutrients
–Provide liquid nutritional supplements, enteral nutrition, or total parenteral nutrition, as prescribed

• Perform ongoing nutritional assessment
–Use of a standardized nutrition assessment tool, such as the Mini Nutritional Assessment (MNA), can assist in

determining the extent of malnutrition
• Assess body composition (height and weight), and for alteration in laboratory values (e.g., serum albumin, prealbumin, and

Hgb), which can indicate malnutrition
› Manage moisture and maintain skin integrity—cleanse and dry skin after each incontinent event; use noncytotoxic cleansers

to avoid drying or irritating skin; do not rub the skin(14)

• For incontinent patients, use special supplies (e.g., topical skin barriers, a pouching system, or indwelling catheters) and
frequently inspect skin

• For patients with dry skin, use moisturizer frequently because dry skin is more susceptible to breakdown
› Minimize pressure, friction, and shear(6,14)

• Use heel protective devices (Figure 2) for patients at high-risk for PIs
• Provide a pressure-redistributing support surface instead of a standard mattress, per clinician orders or facility protocol

(Figure 3)

Figure 2: The convoluted foam of the heel protector increases cushioning, promotes air circulation, and
dissipates heat for protection against skin breakdown. Copyright ©2015, EBSCO Information Services

Figure 3: Example of continuous pressure air-suspension mattress overlay that is utilized to
reduce the risk for pressure injury development. Copyright© 2014, EBSCO Information Services

• Use lift sheets, overhead trapeze bars, and hoists; do not drag or pull the patient
• Reposition the patient frequently

–Turn the patient every 1–2 hours using a hoist, trapeze, or lift sheet
–Use pressure-redistributing devices (e.g., pillows, wedges) to reduce pressure on bony prominences; frequently evaluate

their effectiveness
– Avoid use of donut-type ring cushions as support devices because they can increase the size of the PI by causing further

ischemia rather than reducing risk for PI development
–Do not massage bony prominences (6)

› Educate patient and family about PI etiology, risk factors, and prevention strategies (e.g., good nutrition, regular inspection
of skin, frequent repositioning), and when to seek medical attention

Coding Matrix
References are rated using the following codes, listed in order of strength:

M Published meta-analysis

SR Published systematic or integrative literature review

RCT Published research (randomized controlled trial)

R Published research (not randomized controlled trial)

C Case histories, case studies

G Published guidelines

RV Published review of the literature

RU Published research utilization report

QI Published quality improvement report

L Legislation

PGR Published government report

PFR Published funded report

PP Policies, procedures, protocols

X Practice exemplars, stories, opinions

GI General or background information/texts/reports

U Unpublished research, reviews, poster presentations or
other such materials

CP Conference proceedings, abstracts, presentation

References
1. Black, J.M., Goldberg, M., McNichol, L., & Moore, L. (2016). Revised national pressure ulcer advisory panel pressure injury staging system: Revised pressure injury staging

system. Journal of wound, ostomy, and continence nursing, 43(6), 585-597. doi:10.1097/WON.0000000000000281 (G)

2. Centers for Medicare & Medicaid Services. (2020, February 11). Hospital-acquired conditions. Retrieved June 15, 2020, from
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html (GI)

3. Cogan, A. M., Blanchard, J., Garber, S. L., Vigen, C., Carlson, M., & Clark, F. A. (2017). Systematic review of behavioral and educational interventions to prevent pressure
ulcers in adults with spinal cord injury. Clinical Rehabilitation, 31(7), 871-880. doi:10.1177/0269215516660855 (SR)

4. Doh, G., & Heo, C.Y. (2021). Pathogenesis and prevention of pressure ulcer. Journal of the Korean Medical Association, 64(1), 16-25. doi:10.5124/jkma.2021.64.1.16 (RV)

5. Dunk, A. M., & Carville, K. (2016). The international clinical practice guidelines for prevention and treatment of pressure ulcers/injuries. Journal of Advanced Nursing, 72(2),
243-244. doi:10.1111/jan.12614 (G)

6. European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury
Alliance. (2016). Prevention and treatment of pressure ulcers: Quick reference guide. Retrieved June 15, 2021, from
http://www.npuap.org/wp-content/uploads/2014/08/Updated-10-16-14-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf (G)

7. Kim, J. Y., & Cho, E. (2017). Evaluation of a self-efficacy enhancement program to prevent pressure ulcers in patients with a spinal cord injury. Japan Journal of Nursing
Science, 14(1), 76-86. doi:10.1111/jjns.12136 (RCT)

8. Markova, A. (2019). Pressure ulcer terminology. European Pressure Ulcer Advisory Panel. Retrieved June 15, 2021, from
http://www.epuap.org/news/pressure-ulcer-terminology/ (GI)

9. McInnes, E., Jammali-Blasi, A., Bell-Syer, S. E., Dumville, J. C., Middleton, V., & Cullum, N. (2015). Support surfaces for pressure ulcer prevention. Cochrane Database of
Systematic Reviews, Issue 9. Art. No.: CD001735. doi:10.1002/14651858.CD001735.pub5 (M)

10. National Institute for Health and Care Excellence (NICE). (2015). Pressure ulcers. Retrieved June 25, 2021, from
https://www.nice.org.uk/guidance/qs89/resources/pressure-ulcers-pdf-2098916972485 (G)

11. National Pressure Ulcer Advisory Panel. (2016, April 13). National Pressure Ulcer Advisory Panel (NPUAP) announces a change
in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury. Retrieved June 15, 2021, from
http://www.npuap.org/national-pressure-ulcer-advisory-panel-npuap-announces-a-change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the-stages-of-pressure-injury/
(G)

12. VanGilder, C., Lachenbruch, C., Algrim-Boyle, C., & Meyer, S. (2017). The International Pressure Ulcer Prevalence™ Survey: 2006-2015: A 10-year pressure injury prevalence
and demographic trend analysis by care setting. Journal of Wound, Ostomy, and Continence Nursing, 44(1), 20-28. doi:10.1097/WON.0000000000000292 (R)

13. Walker, R.M., Gillespie, B.M., Mcinnes, E., Moore, Z., Eskes, A.M., Patton, D., & Chaboyer, W. (2020). Prevention and treatment of pressure injuries: A meta-sythesis of
Cochrane Reviews. Journal of Tissue Viability, 29(4), 227-243. doi:10.1016/j.jtv.2020.05.004 (M)

14. Welesko, M.-B., & Javier, N. M. (2018). Pressure injury. In F. F. Ferri (Ed.), 2018 Ferri’s clinical advisor: 5 books in 1 (pp. 1056-1058). Philadelphia, PA: Elsevier. (GI)

15. Zack, A. M. (2018). Pressure ulcer. In F. J. Domino (Ed.), The 5-minute clinical consult 2018 (26th ed., pp. 808-809). Philadelphia, PA: Wolters Kluwer. (GI)

Adapted from the PICOT Questions Template; Ellen Fineout-Overholt, 2006. This form may be used for educational & research purposes without permission.

Template
 for
 Asking
 PICOT
 Questions
 

INTERVENTION
 

In
 ____________________(P),
 how
 does
 ____________________
 (I)
 compared
 to
 

____________________(C)
 affect
 _____________________(O)
 within
 ___________(T)?
 
 

 

THERAPY
 

In
 __________________(P),
 what
 is
 the
 effect
 of
 __________________(I)
 compared
 to
 

_____________
 (C)
 on
 ________________(O
 within
 _____________(T)?
 

 

PROGNOSIS/PREDICTION
 
In
 ______________
 (P),
 how
 does
 ___________________
 (I)
 compared
 to
 _____________(C)
 

influence
 __________________
 (O)
 over
 _______________
 (T)?
 

 

DIAGNOSIS
 OR
 DIAGNOSTIC
 TEST
 

In
 ___________________(P)
 are/is
 ____________________(I)
 
 compared
 with
 

_______________________(C)
 more
 accurate
 in
 diagnosing
 _________________(O)?
 

 

ETIOLOGY
 

Are____________________
 (P),
 who
 have
 ____________________
 (I)
 compared
 with
 those
 

without
 ____________________(C)
 at
 ____________
 risk
 for/of
 

____________________(O)
 over
 ________________(T)?
 
 

 

MEANING
 

How
 do
 _______________________
 (P)
 with
 _______________________
 (I)
 
 perceive
 

_______________________
 (O)
 during
 ________________(T)?
 

 

 

 

 

 

Adapted from the PICOT Questions Template; Ellen Fineout-Overholt, 2006. This form may be used for educational & research purposes without permission.

 

Short
 Definitions
 of
 Different
 Types
 of
 Questions
 

 
Intervention/Therapy:
 Questions
 addressing
 the
 treatment
 of
 an
 illness
 or
 disability.
 

 
Etiology:
 Questions
 addressing
 the
 causes
 or
 origins
 of
 disease
 (i.e.,
 factors
 that
 produce
 or
 
predispose
 toward
 a
 certain
 disease
 or
 disorder).
 

 
Diagnosis:
 Questions
 addressing
 the
 act
 or
 process
 of
 identifying
 or
 determining
 the
 nature
 and
 
cause
 of
 a
 disease
 or
 injury
 through
 evaluation.
 

 
Prognosis/Prediction:
 Questions
 addressing
 the
 prediction
 of
 the
 course
 of
 a
 disease.
 

 
Meaning:
 Questions
 addressing
 how
 one
 experiences
 a
 phenomenon.
 

 

Sample
 Questions:
 

 
Intervention:
 In
 African-­‐American
 female
 adolescents
 with
 hepatitis
 B
 (P),
 how
 does
 
acetaminophen
 (I)
 compared
 to
 ibuprofen
 (C)
 affect
 liver
 function
 (O)?
 

 
Therapy:
 In
 children
 with
 spastic
 cerebral
 palsy
 (P),
 what
 is
 the
 effect
 of
 splinting
 and
 casting(I)
 
compared
 to
 constraint-­‐
 induced
 therapy
 (C)
 on
 two-­‐handed
 skill
 development
 (O)?
 

 
Prognosis/Prediction:
 
 
1)
 For
 patients
 65
 years
 and
 older
 (P),
 how
 does
 the
 use
 of
 an
 influenza
 vaccine
 (I)
 compared
 to
 
not
 received
 the
 vaccine
 (C)
 influence
 the
 risk
 of
 developing
 pneumonia
 (O)
 during
 flu
 season
 
(T)?
 
 
2)
 In
 patients
 who
 have
 experienced
 an
 acute
 myocardial
 infarction
 (P),
 how
 does
 being
 a
 
smoker
 (I)
 compared
 to
 a
 non-­‐smoker
 (C)
 influence
 death
 and
 infarction
 rates
 (O)
 during
 the
 
first
 5
 years
 after
 the
 myocardial
 infarction
 (T)?
 

 
Diagnosis:
 In
 middle-­‐aged
 males
 with
 suspected
 myocardial
 infarction
 (P),
 are
 serial
 12-­‐lead
 
ECGs
 (I)
 compared
 to
 one
 initial
 12-­‐lead
 ECG
 (C)
 more
 accurate
 in
 diagnosing
 an
 acute
 
myocardial
 infarction
 (O)?
 

 
Etiology:
 Are
 30-­‐
 to
 50-­‐year-­‐old
 women
 (P)
 who
 have
 high
 blood
 pressure
 (I)
 compared
 with
 
those
 without
 high
 blood
 pressure
 (C)
 at
 increased
 risk
 for
 an
 acute
 myocardial
 infarction
 (O)
 
during
 the
 first
 year
 after
 hysterectomy
 (T)?
 

 
Meaning:
 How
 do
 young
 males
 (P)
 with
 a
 diagnosis
 of
 below
 the
 waist
 paralysis
 (I)
 perceive
 
their
 interactions
 with
 their
 romantic
 significant
 others
 (O)
 during
 the
 first
 year
 after
 their
 
diagnosis
 (T)?