Pressure Injury Risk in Specific Populations
Published online: 06 September 2026
Suggested citation
National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Pressure Injury Risk in Specific Populations.. In: Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline: Fourth Edition. Emily Haesler (Ed.). 2026. [cited: download date]. Available from: https://internationalguideline.com.
Introduction
The pressure injury (PI) risk factor domains broadly relevant to most adult individuals are presented in the guideline chapter Pressure Injury Risk. The domains discussed in the chapter Pressure Injury Risk are relevant to adults, regardless of population or setting.
This chapter provides an overview of population-specific PI risk factors. The evidence review considered studies that included a multivariable analysis. Studies were prioritized as follows:
recent systematic reviews and meta-analyses,
large multi-site studies with broad representation of the population,
large single-site studies using artificial intelligence strategies, and
multiple single-site studies that identify similar unique risk factors for the population.
If already analyzed in a systematic review, individual studies were excluded. Systematic reviews were evaluated using AMSTAR-2 criteria.
It is beyond the scope of this discussion to include specific preventive interventions that address population-specific risk factors. Throughout this clinical guideline, implementation consideration provided with the best practice statements and recommendations provide relevant population-specific clinical guidance.
Risk Factors in Specific Populations
RKSP1: Good Practice Statement
It is good practice to assess additional risk factors that are unique to specific populations and settings.
More information
Clinical question: What are the unique pressure injury risk factors to consider for specific populations, settings and clinical circumstances?
Supporting information
Specific populations have unique additional PI risk factors arising from specific clinical backgrounds and/or the clinical settings in which they are receiving care. To conduct a comprehensive risk assessment for, it is important to consider population-specific risk factors, in addition to risk factors considered in routine risk screening and assessment. Additionally, population-specific risk assessment tools are an option. There are numerous examples of population-specific risk tools that combine features of general and population-specific risk factors relevant to a specific population.
Pressure Injury Risk for Individuals in the Operating Room
RKSP2: Good Practice Statement
For individuals in the operating room, it is good practice to consider the impact on surgery-related pressure injury risk of:
time spent immobilized before surgery,
duration of surgery,
American Society of Anesthesiologist (ASA) Physical Status Classification, and
multiple comorbidities (e.g., respiratory disease, cardiovascular disease and diabetes mellitus).
More information
Clinical question: What are the unique pressure injury risk factors to consider for specific populations, settings and clinical circumstances?
Implementation considerations
Consider surgery-specific risk factors in light of all other risk factors discussed in the guideline chapter Pressure Injury Risk.
Identify individuals with planned lengthy operative times in advance to enable the early introduction of support surfaces, positioning devices, positioning strategies and preventive dressings to reduce PI risk.
Pay particular attention to the pressure points associated with different surgical positions when planning and implementing surgical positioning. The guideline chapter Repositioning and Mobilization provides diagrams of a selection of surgical positions.
Where possible, minimize the time of immobilization before and after surgery.
For additional guidance on PI strategies in the perioperative setting, refer to the AORN Prevention of Pressure Injury Guideline (available through the AORN website to AORN members).
Supporting information
Xu et. al. (2025) (1) conducted a systematic review and meta-analysis of intraoperative PI risk prediction models (n = 26,142 individuals undergoing surgery). The most common PI risk factors included surgery duration, age, and diabetes. Areas Under the Curve (AUC) for models’ values varied from 0.702 to 0.984. Taghiloo et al. (2023) (2) conducted a systematic review and meta-analysis of studies examining risk factors in adults undergoing cardiovascular surgery. There were statistically significant associations between PI and:
female sex (pooled estimate = 1.551, 95% confidence interval [CI] 1.199 to 2.006, z = 3.345, p = 0.001),
diabetes (pooled estimate = 1.985, 95% CI 1.383 to 2.849, z = 3.719, p < 0.0001),
advanced age (standardized mean difference [SMD] 0.33 years, 95% CI 0.09 to 0.57),
duration of surgery (SMD 0.47, 95% CI 0.19 to 0.75), and
preoperative serum albumin level (SMD 0.56; 95% CI 0.14 to 0.98).
Haisley et. al., (2020)(3) conducted a systematic review and meta-analysis of 14 studies of adults undergoing surgery under general anesthesia. The analysis identified five factors significantly associated with the development of PIs:
cardiovascular disease (relative risk [RR] 2.24, 95% CI 1.56 to 3.22; p < 0.001),
respiratory disease (RR 3.28, 95% CI 1.89 to 5.71, p < 0.001),
diabetes mellitus (RR 1.49, 95% CI 1.29 to 1.71, p < 0.001),
low hemoglobin level (mean difference [MD] 7.94 g/l, 95% CI 13.12 to −2.6, p = 0.003), and
longer duration of surgery (MD 69.81minutes, 95% CI 2.36 to 137.26, p = 0.04).
Risk factors selected as unique to the surgical population include:
duration of surgery or anesthesia (1-5),
time immobilized prior to surgery (6-8),
higher American Society of Anesthesiologist (ASA) (6,9-11)
Physical Status Classification scores (6,9-11), and
multiple comorbidities (e.g., cardiovascular disease, respiratory disease and diabetes mellitus) (1-3,12).
Surgical duration of greater than three to four hours was often defined as a threshold for increased PI risk. Position during surgery was listed by several investigators; however, there was little consistency in the position(s) that carried the highest risk. Prone, lateral and lithotomy positions were listed most often. The prone position is particularly problematic. Xu (2024) (13) conducted a retrospective cohort study specifically comparing PI rates when the prone position was used intraoperatively compared to all non-prone positions. Those in prone position had a 2.92 higher risk of PI than those in non-prone positions. The guideline chapter Repositioning and Mobilization includes further discussion on repositioning in the operating room, including graphic depictions of pressure points of concern.
Several of the generic PI risk factor domains are also identified in the literature as being of pertinence to individuals undergoing surgery, noting that for several of these domains, unique population-specific operational definitions worth were reported (see Table 1).
Table 1: Population-specific examples for risk factor domains for individuals undergoing surgery
| Risk factor domain | Mechanical boundary conditions (MBC) | Susceptibility and tolerance of the individual (ST) | Examples of operation definitions for individuals undergoing surgery |
|---|---|---|---|
| Note: there population-specific risk factors should be considered in addition to the generic PI risk factor domains discussed in the guideline chapter Pressure Injury Risk, Table 1 | |||
| Perfusion, circulation and oxygenation factors | X |
|
|
Assessing PI risk in the Operating Room Setting
Several population-specific PI risk assessment tools are reported in the literature. Three tools, the Munro Scale (14-21), The Scott Triggers tool (22, 23), and the Escala de Avaliação de Risco para Lesões Decorrentes do Posicionamento Cirúrgico (24, 25) (ELPO Tool), include a range of different risk factors, as summarized in Table 2, the psychometric properties for which have been reported (see Table 3). In addition, the Surgery-Related Pressure Injury Risk Assessment Scale (SURPIRAS) (25, 26) has also been reported, but to our knowledge, the psychometric properties have not been reported in a synthesis.
Pressure Injury Risk for Individuals in the Critical Care
RKSP3: Good Practice Statement
For individuals in critical care, it is good practice to consider the impact on pressure injury risk of:
duration of critical care unit stay,
mechanical ventilation,
inadequate oxygenation,
poor perfusion,
shock states,
vasopressor use, type, dose and duration,
Acute Physiology and Chronic Health Evaluation (APACHE II, III, or IV) Scale,
Simplified Acute Physiology Score (SAPS), and
Sequential Organ Failure Assessment (SOFA) Scale.
More information
Clinical question: What are the unique pressure injury risk factors to consider for individuals in critical care?
Implementation considerations
Consider critical care-specific risk factors in light of all other risk factors discussed in the guideline chapter Pressure Injury Risk.
Undertake intensive efforts to address modifiable risk factors (e.g., selection of support surfaces, small shifts in body position, early nutritional supplementation). Implementation considerations for the recommendations and good practice statements in the guideline chapters Repositioning and Mobilization, Full Body Support Surfaces and Nutrition for Pressure injury Prevention and Treatment address specific needs of individuals in critical care settings.
Consider the high burden of device related pressure injuries (DRPIs) in individuals in critical care. More information is provided in this chapter, and in the guideline chapter Device Related Pressure Injuries.
When the burden of non-modifiable risk factors is extremely high, PIs may be unavoidable despite best efforts at prevention (86,87). The skin may fail as other organs fail; however, acute skin failure does not have a universally accepted definition (88).
Differentiate PIs from other skin and tissue anomalies commonly found in critically ill individuals (e.g., disease related skin changes, skin manifestations of COVID-19, purpura and drug reactions) (89-92).
Describe symptoms of hypo-perfused skin on both loaded and non-loaded surfaces (e.g., mottling, slow capillary refill, pallor, purple discoloration.
Consider PIs in the differential diagnosis if skin and tissue changes occur exclusively on pressure loading surfaces and not on other skin surfaces (88).
If available, consider long wave infrared thermography (LWIT) to help differentiate deep tissue pressure injury (DTPI) from skin failure and other types of superficial skin damage (93,94). More information is available in the guideline chapter Advanced Technologies for Skin and Tissue Assessment.
Supporting information
Critical care-specific risk factors often cannot be modified with a PI prevention program. They do, however, create a greater likelihood of PI. The higher burden of risk created by these non-modifiable risk factors may prompt more intensive efforts in addressing modifiable risk factors. Population-specific risk factors include duration of critical care unit stay (45-47), mechanical ventilation (45, 48), duration of vasopressors (45-49) and assessment results on three assessment scales commonly used in critical care settings—the Acute Physiology and Chronic Health Evaluation (APACHE II or III) Scale (45-50), the Simplified Acute Physiology Scores (SAPS) (51) and the Sequential Organ Failure Assessment (SOFA) Scale (45, 52-53).These factors are summarized on Table 4.
Alderden et al. (2025) (46) provided a comprehensive update of a previous systematic review (54) without meta-analysis that included 33 studies exploring PI risk factors for adult critically ill individuals. Older age, limited mobility or activity, impaired perfusion, vasopressor use, and longer intensive care unit length of stay were the most consistently identified independent risk factors (46). Diabetes mellitus also emerged as a notable risk factor in several high-quality studies, although evidence was mixed. Inconsistent measurement approaches for nutrition and skin status limited conclusions regarding the impact of these factors.
Tang et al. (2022) (50) conducted a systematic review and meta-analysis of the relationship between Acute Physiology and Chronic Health Evaluation (APACHE) scores and pressure injury development. Twenty-one observational studies including 11,102 subjects were examined. Higher APACHE scores were significant predictors of PI across studies. The pooled SMD (standardized mean difference) was 0.82 (95% CI: 0.58-1.06, p <0.001). There were no significant differences between versions of the tool (i.e., APACHE II, III, IV).
Vasopressors
Vasopressors are a category of medications that are used to raise blood pressure and restore blood flow to vital organs through different pathways depending on the specific class of the vasoactive agent. These medications are often used in the critical setting to stabilise individuals who are in shock or cardiac arrest. Their use has been associated with increased PI risk, with several studies reporting that the vasopressor associated with the greatest impact on PI development is vasopressin (also known as argipressin) (51, 55, 56).
It should be noted that a meta-analysis (57) found that when all types were combined, shock state itself did not emerge as significant independent risk factor for PI. The exception was septic shock, which was shown to be associated with a higher rate of PI development (odds ratio [OR] 1.75, 95% CI 1.29 to 2.38). Thus, it appears the increased risk of PIs in individuals receiving vasopressors is associated with the medication rather than solely attributed to disease processes. Two systematic reviews focused on the relationships between vasopressor use and PI risk in critical care. Tang et. al. (2023) (49) completed a systematic review of 26 studies (n = 50,192 individual patients). Vasoconstrictor drugs were a significant risk factor for PI development (pooled adjusted odds ratio [OR] 1.83, 95% CI 1.25 to 2.68, p = 0.002, 20 studies). McEvoy, et. al. (2022) (47), conducted a systematic review and meta-analysis of critically ill individuals receiving vasopressors. The two included studies compared subjects with and without vasopressors (56, 58), and found significantly higher PI rates in the cohorts receiving vasopressors. In studies where all individuals received vasopressors, those developing PIs had longer duration of vasopressor use (p = 0.00001), received higher vasopressor doses (p = 0.00001), and had a longer length of stay (p = 0.00001).
Duration of critical care stay is associated with PI development based on greater acuity of illness and longer duration of risk exposure; however, it should be noted that it does not meet the classic definition that requires a risk factor precede the disease/clinical condition.
Table 4: Population-specific examples for risk factor domains for individuals in critical care settings
| Risk factor domain | Mechanical boundary conditions (MBC) | Susceptibility and tolerance of the individual (ST) | Examples of operation definitions for individuals in critical care |
|---|---|---|---|
| Note: there population-specific risk factors should be considered in addition to the generic PI risk factor domains discussed in the guideline chapter Pressure Injury Risk, Table 1 | |||
| Perfusion, circulation and oxygenation factors | X |
|
|
| General health status | X |
X |
|
| Other Demographic variables | X |
|
|
Assessing PI risk in the Critical Care Setting
Several population-specific PI risk assessment tools are reported in the literature. These include the Critical Care Pressure Ulcer Assessment Tool Made Easy (CALCULATE) (67-70), the COnsciousness, Mobility, Haemodynamics, Oxygenation, Nutrition (COMHON) Index (68, 71-80), Cubbin-Jackson Scale (31, 81-84), Escala de Valoración Actual del riesgo de desarrollar Úlceras por presión en Cuidados Intensivos (EVARUCI Scale) (75, 80), and the Risk Assessment Pressure Injury Scale for the Intensive Care Unit (RAPS-ICU) (75, 85). Domains included in these tools are reported on Table 5 and the psychometric properties of the tools is summarized in Table 6.
Pressure Injury Risk for Neonates and Children
RKSP4: Good Practice Statement
For neonates and children, it is good practice to consider the impact on pressure injury risk of:
skin maturity,
perfusion and oxygenation,
presence of a medical device, malnutrition,
illness severity,
surgery, and
duration of critical care stay.
Clarifiers:
Risk factors for pressure injury development may vary by age group in the pediatric population.
Medical devices are a leading cause of pressure injury in the pediatric population.
Different risk factor profiles are seen in device-related pressure injury versus immobility-related pressure injuries in the pediatric population.
More information
Clinical question: What are the unique pressure injury risk factors to consider for neonates and children?
Implementation considerations
Undertake intensive efforts to address modifiable risk factors. Implementation considerations for the recommendations and good practice statements throughout the guideline address specific needs of neonates and children.
Be aware of, and target assessment and prevention towards risk factors commonly found in various pediatric age groups.
Device related pressure injuries
Consider the high burden of DRPI (especially respiratory medical devices) in neonates and children (105, 113, 116, 120).
Select medical devices for children based on the best fit for their intended purpose and least potential for injury. Regularly check the fitting and position of all devices. More information is provided in this chapter, and in the guideline chapter Device Related Pressure Injuries.
Be aware of the general risk factors for DRPI in the pediatric population including surgery, low hemoglobin, constantly moist skin, excessively dry skin and malnutrition (105); younger age (especially low birth weight and 0–2-year age group), decreased sensory perception, persistently moist skin, and increased number of medical devices (especially respiratory support devices) (119).
Prevent moist skin and edema, particularly in the context of tight devices. The combination of these factors is of particular concern in DRPI development. The guideline chapters on Preventive Skin Care and Device Related Pressure Injuries provide more implementation considerations specific to neonates and children.
Be alert to nonverbal signs of discomfort. Anticipate causes of DRPI discomfort in individuals with decreased sensory perception. Infants, young children and any child with decreased sensory perception and/or limited verbal skills may not be able to alert staff to discomfort under a device.
Non-device related pressure Injuries
Focus on pressure redistribution/offloading under the occiput from infancy to 5 years of age. The head is proportionally larger and heavier in this age group (120).
Start focusing on heels, sacrum and coccyx in school-age and adolescent children. As children age, the head-to-body proportions become increasing like those of adults. By puberty, locations of typical adult PIs (sacrum coccyx, heels) are seen more frequently, although DRPI is still the primary concern (105)
Supporting information
Neonates and children have a different risk profile for pressure injury (PI) development than adults. Developmental changes such as skin maturity, greater head-to-body distribution in infants and young children and ages of complete bone ossification have a significant effect on boundary conditions, tissue tolerance to pressure and risk factors for both DRPI pressure injuries and bony prominence pressure injuries. Many of the common sites of bony prominence pressure injuries do not reach full ossification until adulthood (e.g., coccyx, ischial tuberosity, trochanter, and calcaneus) (105). Even within the pediatric population. risk factors for PI development may vary by age group (105, 106.) Population-specific risk factors include the impact of skin maturity (107-09,) perfusion and oxygenation (106, 110-114), presence of a medical device (105, 115, 116), illness severity (117), surgery (106, 112, 113) and duration of critical care stay (118, 119). The risk factors are summarized in Table 7.
Additionally, a multivariable analysis that have analyzed risk profiles by age group have identified the following most common risk factors for development of any PI (105):
38 weeks gestation to 12 months: surgery
1 to 7 years: surgery, decreased sensory perception
8 to 21 years: surgery, decreased sensory perception, tissue perfusion and oxygenation – generalized edema, skin constantly moist.
Total sample: surgery, decreased sensory perception, tissue perfusion and oxygenation – generalized edema and oxygen use, low hemoglobin, skin constantly moist, skin excessively dry, malnutrition.
A second analysis (106) focused on risk factors for full thickness PIs. Premature infants had the highest proportions of full thickness pressure injuries. With thin immature skin and less adipose tissue, full thickness PIs may develop more easily. The analysis identified risk factors analyzed risk profiles by age group and reported those factors most associated with development of full thickness PIs (106):
Full term infants to 1 year: generalized edema, surgery, nutritional deficits requiring tube feeding or total parenteral nutrition.
1 to 7 years: fragile skin.
8 to 21 years: ECMO, decreased perfusion and oxygenation requiring oxygen use.
Total sample: ECMO, decreased perfusion and oxygenation requiring oxygen use, malnutrition.
Skin immaturity
In full-term neonates skin generally has a well-developed epidermis and stratum corneum, although it is still developing (109). In contrast, premature neonates have under-developed skin that has fewer stratum corneum layers and provides an immature barrier function with increased fragility (107, 108, 109). Immature skin has impaired thermal properties and increased permeability, leading to water and electrolyte imbalance (109). Nie et. al. (2022) (107) summarized the structural differences in skin from 20 weeks gestation to adulthood, emphasizing the increased risk of PIs in premature infants and neonates based on these differences. The skin’s protective and absorption properties are of particular concern in gestational ages under 32 weeks. In this age group, the skin may be drier and scalier. This is generally addressed through humidity management in the neonate ICU. Immature skin places the neonate at higher risk of skin damage from pressure and shear (108, 109).
Medical devices
In the pediatric population, medical devices are a leading cause of PIs (113, 115, 116, 120). In a meta-review of five systematic reviews with pediatric populations (n = 56,571) (115), the pooled incidence of hospital-associated pressure injuries (HAPIs) was 8% (95% CI 4% to 13%) and the pooled incidence of DRPIs was 9% (95% CI 2% to 9%). The pooled prevalence of HAPI was 9% (95% CI 5% to 14%) and for DRPI the pooled prevalence was 14% (95% CI: 6% to 24%). Seventy percent of DRPI were caused by respiratory devices.
Different risk factor profiles are seen in device related PIs (DRPIs) versus immobility-related PIs (106). A systematic review and meta-analysis of DRPI in pediatric inpatients (119) provided pooled incidence and prevalence rates as well as a narrative synthesis of risk factors. Pooled DRPI incidence was 11% (95% CI 5.2 to 22) and pooled DRPI prevalence was12.6 (95% CI to 1.1-65.8). Risk factors included being of younger age (especially in individuals of low birth weight and in the 0–2-year age group), compromised mobility, altered level of consciousness, infection or other co-morbidities, persistently moist skin, increased number of medical devices, prolonged hospital stay, non-invasive ventilation, endotracheal tube intubation, feeding tubes, inotropic or sedative medication, lower Braden QD scores or higher e-NSRAS scores. Respiratory support devices were the most common causes, followed by monitoring devices, vascular access devices, gastrointestinal devices and immobilization/support devices. Nie et al. 2025 (105) conducted a retrospective analysis of 799 hospitalized pediatric patients. 82.9% of PIs were caused by medical devices; 17.1% were considered immobility related. Logistic regression analysis of the entire sample identified several risk factors for DRPIs, including surgery, low hemoglobin, persistently moist skin, excessively dry skin and malnutrition. In immobility related PIs, sensory perception was the only significant factor. Immobility was not a bivariate or multivariate significant risk factor for immobility related PIs (105).
Table 4: Population-specific examples for risk factor domains for neonates and children
| Risk factor domain | Mechanical boundary conditions (MBC) | Susceptibility and tolerance of the individual (ST) | Examples of operation definitions for neonates and children |
|---|---|---|---|
| Activity and mobility limitations | X |
|
|
| Moisture | X |
X |
|
| Skin and tissue status | X |
|
|
| Perfusion, circulation and oxygenation factors | X |
|
|
| Perfusion, circulation and oxygenation factors | X |
|
|
| Nutrition indicators | X |
|
|
| Body temperature | X |
|
|
| Demographic Variables: Extremes in age | X |
X |
|
| Medical devices | X |
|
Assessing PI risk in neonates and children
Structural differences in the skin of neonates, babies and infants make PI classification systems designed for adults particularly difficult to administer and not entirely appropriate in this population (107). Population specific risk assessment tools for neonates and children include Braden Q and QD (124, 131, 134-137), NSRAS (Neonatal Skin Risk Assessment Scale)(127, 138, 139) Glamorgan Scale (140), and PPUPET (Pediatric Pressure Ulcer Prediction and Evaluation Tool) (128, 129). Domains included in these tools are summarized in Table 8 and psychometric properties of the tools are reported in Table 9.
Pressure Injury Risk for Individuals with Spinal Cord Injury
An individual with a spinal cord injury faces a life-long risk of pressure injuries. In addition to the obvious risk factors of immobility and decreased sensory perception, physiological changes secondary to spinal cord injury make skin and other tissue more vulnerable to the effects of mechanical loads. These physiological changes include vascular dysfunction (e.g., impaired blood flow, altered vasomotor control, autonomic dysregulation, endothelial dysfunction) (141, 142), changes in body composition and distribution (e.g., loss of extracellular matrix support below the level of injury, loss of muscle mass, increased intramuscular fat, increased adipose tissue) (143, 144, 145, 146), and increases in inflammatory biomarkers (147, 148). Changes in tissue structures alter the tissue’s ability to withstand mechanical loads. Vascular dysfunction affects the ability to re-perfuse ischemic tissues. Spasticity increases shear forces.
RKSP5: Good Practice Statement
For individuals with spinal cord injury, it is good practice to consider the impact on pressure injury risk of:
higher level of spinal cord injury,
more severe American Spinal Injury Association Impairment (ASIA) Scale,
mechanical ventilation, and
lower Functional Independence Measure (FIM) scores.
More information
Clinical question: What are the unique pressure injury risk factors to consider for individuals with spinal cord injury?
Implementation considerations
Consider risk factors specific to individuals with SCI in light of all other risk factors discussed in the guideline chapter Pressure Injury Risk.
Risk stratification for individuals with SCI might assist in differentiating individuals with the highest PI risk. The Agency for Clinical Innovation (New South Wales Government) provides a resource that considers personal and environmental factors (open risk stratification tab).
Additional information on specific prevention strategies for individuals with spinal cord injuries can be found in chapters on Skin and Tissue Assessment, Preventive Skin Care, Repositioning and Mobilization, Pressure Injuries in Seated Individuals, and Device Related Pressure Injuries.
Supporting information
Three systematic reviews with meta-analyses reported on the incidence and prevalence of PIs in individuals with spinal cord injury (SCI) (149-151). The most recent review, with over 150,000 patients, reported an overall PI incidence of 28.8% (95% CI 24.2% to 33.4%).(151) The greatest number of PIs were in the sacrococcygeal region (28.8%) followed by the sciatic tuberosities (12.9%) and heels (12.3%) (151). Population-specific risk factors are summarized in Table 10.
Table 10: Population-specific examples for risk factor domains for individuals with spinal cord injury
| Risk factor domain | Mechanical boundary conditions (MBC) | Susceptibility and tolerance of the individual (ST) | Examples of operation definitions for individuals with spinal cord injury |
|---|---|---|---|
| Note: there population-specific risk factors should be considered in addition to the generic PI risk factor domains discussed in the guideline chapter Pressure Injury Risk, Table 1 | |||
| Activity and mobility limitations | X |
|
|
| Perfusion, circulation and oxygenation factors | X |
|
|
| Nutrition indicators | X |
|
|
| Sensory perception limitations: local or systemic | X |
|
|
| Demographic Variables | X |
X |
|
| General health status | X |
X |
|
Assessing PI risk in individuals with spinal cord injury
Population-specific risk assessment tools include SCIPUS (Spinal Cord Injury Pressure Ulcer Scale) (32, 35, 168, 169, 170, 171) and PreSORS SCI (Pressure Sore Onset Risk Screening) (44). Domains included on these tools are presented on Table 2 and their psychometric properties are included on Table 3.
Risk Factors for Heel Pressure Injuries
Heels are often cited as the second or third most common site of pressure injuries in adults (172, 173). The unique anatomy of the heel makes it vulnerable to pressure injury. In adults, the posterior aspect of the heel rim is particularly vulnerable, even when a support surface with pressure redistribution properties is used (174). In standing or sitting positions, normal stresses are transmitted via the Achilles tendon and the plantar fascia, and the heel rim is not directly weight-bearing; however, in supine position the heel is weight-bearing. Mechanical loads are transmitted directly perpendicular to the bone, and the posterior aspect of the heel is covered with only a small volume of subcutaneous tissue (175). The shape of the individual’s calcaneus (176), and the posture of the foot (177), normally influence the strain on muscles and tissue at the heel.
The anatomy of the heel creates the greatest risk for pressure injury. Studies of risk factors in patients who developed pressure injuries of the heel were reviewed. The risk factors reported most likely exacerbate the existing risk created by the anatomy of the heel.
RKSP6: Good Practice Statement
It is good practice to consider factors that decrease perfusion and increase friction and shear to the heel area, including:
peripheral arterial disease,
systemic perfusion issues (e.g., shock states),
use of vasopressors,
diabetes mellitus, and
high potential for friction and shear.
More information
Clinical question: What are the unique pressure injury risk factors to consider for heels?
Supporting information
In a systematic review without meta-analysis, Dube et. al. (2022) (178) reported the following as potential risk factors for heel PIs based on three high-quality studies: diabetes, vascular disease, immobility, friction and shear (as measured by a Braden Scale subscore), perfusion issues and surgery. Studies in critical care specifically cite vasopressors as a risk factor for heel PIs due to the significant decrease in perfusion to the foot and other peripheral areas (179, 180). Population-specific risk factors that contribute to heel PIs include peripheral arterial disease (178, 180, 181) systemic perfusion issues (e.g., shock states) (178, 181), use of vasopressors,(179, 180), diabetes mellitus (178, 181), and high potential for friction and shear (178, 182). The guideline chapter Preventing Heel Pressure Injuries includes more discussion on the anatomical factors that are associated with PIs at the heel, and preventive strategies.
Risk Factors for Device Related Pressure Injuries
RKSP7: Good Practice Statement
It is good practice to consider the presence of a medical device as a risk factor. Risk factors specific to device related pressure injuries for adults include:
edema,
greater duration of device use,
greater number of total devices in use,
device design and materials.
Risk factors specific to device related pressure injuries for adults in critical care settings include:
vasopressors,
surgery, ventilator use,
prone position ventilation,
higher APACHE II/III Scale score, and
higher score SOFA Scale score.
Clarifiers:
Regardless of age or clinical setting, an individual should be considered at risk of a PI as soon as a device has been applied.
General categories of risk for DRPI include the (1) design and materials used to make the device, (2) how the device is fitted, secured and monitored, (3) characteristics of the interface between the device and skin (e.g., adhesive, pressure points, heat and moisture), and (4) intrinsic patient tissue tolerance factors.
Constellations of risk factors may vary depending on the device.
More information
Clinical question: What are the unique pressure injury risk factors to consider in the context of device related pressure injuries?
Implementation considerations
Select devices with the primary purpose of meeting a medical need. When multiple device designs will address the medical need, select devices that:
are comfortable for the individual,
fit the contours of the skin/tissue interfacing with the device,
less likely to retain moisture at the skin-device interface,
least “stiff”, and
distribute pressure evenly over the contact area, avoiding sharp edges.
Use hard bite blocks only when necessary to maintain endotracheal tube patency. Bite blocks increase the risk of oral MMPI. Individuals with bite blocks are between 1.88 (183) and 4.21 (185) times more likely to develop oral PIs.
Evaluate generalized edema and edema under medical devices routinely. Daily fluid shifts may alter the tissue under and around the device requiring periodic adjustment of device securement.
Remove devices when no longer medically indicated.
Review the guideline chapter Device Related Pressure Injuries for more detailed guidance on preventing PIs associated with devices.
Supporting information
Eight systematic reviews of DRPI were identified that conducted meta-analyses on risk factors (45, 65, 183-188). Table 11 provides an overview of DRPI risk factors identified in these reports. The setting for six of the reviews was critical care (45, 65, 183, 184, 185, 186), one was set in a hospital setting (187) and one reported data from multiple settings.(188) Five reviews focused on specific medical devices including endotracheal tubes (183-186), orthopedic devices (187), and non-invasive ventilation devices (NIV) (188).
The risk factor that is reported as significant across all reviews is duration of device use. The number of devices was a significant factor in one study (45), noting this risk factor was not examined in other studies. Wei et. al. (2023) found significant differences in the design of NIV devices. For example, devices with an interface in contact with a greater area of the face were less likely to cause PIs (189). Design materials are difficult to evaluate without mechanical engineering testing; however, devices that are less stiff (yet still perform their intended function) are preferrable. Solmos et. al. (2023) (190) found a significant correlation between device stiffness and severity of pressure injuries.
In critical care, DRPI is often associated with edema (45, 65, 188), vasopressors (45, 65, 183-186), surgery, ventilator use (65), prone position ventilation (65, 183-186), higher APACHE II/III scores (45, 65, 183-186), and higher SOFA scores (45, 65). These factors may decrease tissue tolerance and exacerbate the mechanical effects of the device. A unique risk factor found in a subgroup of subjects with endotracheal tubes was the use of a hard “bite block” to prevent occlusion of the ETT when a restless patient bites down (183, 184, 185, 186). Bite blocks increase the source and intensity of mechanical pressure on mucosal membranes of the mouth.
Assessing PI risk associated with medical devices
Some risk assessment tools now include the “presence of devices” as a tool item. Several risk assessment tools designed specifically to identify device-related risk are under development with ongoing reliability-validity testing; however, none have been adopted for general clinical use (191-194).
Resources
Resources for selecting a pressure injury assessment tool in specific populations
Table 2: Summary of domains included on pressure injury risk tools designed for use in adults in the operating room or with spinal cord injury
Table 3: Psychometric qualities of major risk assessment tools designed for use in adults in the operating room or with spinal cord injury
Table 5: Summary of domains included on pressure injury risk tools designed for use in adults in critical care settings
Table 6: Psychometric qualities of major risk assessment tools designed for use in adults in critical care or with spinal cord injury
Table 8: Summary of domains included on pressure injury risk tools designed for use in neonates and children
Table 9: Psychometric qualities of major risk assessment tools designed for use in neonates and children
Device related pressure injury risk factors
Table 11: Device related pressure injury risk factors identified in systematic reviews with meta-analyses
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