Pressure Injuries

The National Pressure Ulcer Association Panel (NPUAP) defines a pressure injury as "localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device." (NPUAP "National") According to NPUAP, pressure injuries can present as intact skin or as open ulcers. Pressure injuries can occur for a variety of reasons, and can lead to pain, decreased quality of life, psychological stress, and even death. In 2004, the National Nursing Home Survey found that 11% of nursing home residents had a pressure injury (Park-Lee and Caffrey). Additionally, the annual pressure injury incidence rates in skilled nursing facilities and nursing homes ranges from 2.2% to 23.9% (CMS "Long-stay").

Although many healthcare organizations have adopted programs to identify individuals at risk and take steps to avoid the formation of these painful sores, pressure injuries are still prevalent in healthcare facilities. For example:

The direct and indirect costs of pressure injuries are enormous. One estimate indicates that treating hospitalized patients who have pressure injuries costs the U.S. healthcare system between $9.1 billion and $11.6 billion per year (Becker's). In addition, the development of pressure injuries can result in costly lawsuits for healthcare organizations; for more information, see Pressure Injury Lawsuits.

​In April 2016, the National Pressure Ulcer Advisory Panel (NPUAP) announced a change in terminology for the commonly used term "pressure ulcers." NPUAP suggests using the term "pressure injuries" instead. The change was made to more accurately describe pressure injuries to both intact and ulcerated skin. According to NPUAP, the new term better reflects the fact that less serious degrees of skin damage due to pressure may not actually result in open sores or ulcers and that deep tissue damage can occur without overlying skin ulceration.

We use the term "pressure injury" throughout this guidance article, including when referring to studies published before this classification change that use the term "pressure ulcer" generically without referring to the integrity of the skin. If the term "pressure ulcer" is used in a direct quote, we maintain the term "pressure ulcer."

Pressure injuries—which, besides being called pressure ulcers, have also been referred to as pressure sores, bedsores, decubitus ulcers, and tissue trauma—can be caused by many factors, but are traditionally attributed to a combination of pressure and shearing forces (Berlowitz "Epidemiology"; NPUAP "NPUAP Pressure Injury Stages").

Prolonged pressure on a person's skin causes occlusion of capillary blood flow, especially during sitting or while lying down. Cellular metabolism depends on blood circulation to deliver nutrients to body tissues and to remove waste products. Thus, when circulation is continually diminished over an extended period, tissue death (necrosis) often occurs and pressure injuries develop, especially in the soft tissue areas overlying hard, bony prominences. Healthy people constantly shift their weight and change body position, even when asleep, which prevents tissue damage. But individuals with temporarily or permanently limited mobility cannot change positions and thus are vulnerable to pressure injuries. (Seiler...