RISK FACTORS

Risk Groups for Pressure Injuries

Across all settings the three groups most at risk for pressure injuries are:

• Individuals over 65 years of age (with those over age 75 at even greater risk)
• Neonates and children younger than three
• Individuals of any age with spinal cord injury (with spasticity, the extent of the paralysis, a younger age at onset, difficulty with practicing good skin care, and a delay in seeking treatment or implementing preventive measures increasing the risk of skin breakdown)

Other groups of patients also have a high risk for developing pressure injuries. These include patients who:

• Are in critical care
• Have a fractured hip (which indicates increased risk for heel pressure injuries)
• Have diabetes, secondary to complications from peripheral neuropathy
• Are confined to a wheelchair or bed
• Are immobile or for whom moving requires significant or taxing effort (e.g., morbidly obese)
• Experience incontinence
• Have neuromuscular and progressive neurological diseases (e.g., multiple sclerosis, ALS, Myasthenia gravis, stroke)
• Have neurodegenerative disorders (e.g., Parkinson’s disease, dementia)

Risks due to Aging Skin

Changes in both skin structure and function due to aging contribute to the occurrence of skin problems and decrease wound healing:

• A flattening of the epidermal-dermal junction decreases the overall strength of the skin, which increases the risk for skin tears and blistering.
• A decrease in the melanocytes and Langerhans cells increases the risk for allergic reactions and sensitivity to sunlight.
• A decrease in fibroblast function increases the time required to synthesize collagen.
• A decrease in blood flow decreases skin temperature and delays healing.
• A decrease in oil and sweat production contributes to dryness and flaking.
• A decrease in subcutaneous tissue, especially fat, decreases the body’s natural insulation and padding.
• A decline in the reproduction of the outermost layer of the epidermis may lead to the skin’s inability to absorb topical medications.

These changes in skin structure and function (together with changes in cellular DNA that affect cell reproduction and the ability to protect the skin) and the risks that occur with a change in overall health and functional ability put an aged patient at very high risk for the formation of a pressure injury (WOCN, 2022a; Baranoski & Ayello, 2020).

Other Risk Factors

More than 100 additional risk factors associated with the development a pressure injury have been identified. Some of these include:

• General medical conditions such as diabetes, stroke, multiple sclerosis, cognitive impairment, cardiopulmonary disease, cancer, hemodynamic instability (abnormal/unstable blood pressure), peripheral vascular disease, malnutrition, and dehydration
• Smoking
• History of a previous pressure injury (since scar tissue is weaker than the skin it replaces and breaks down more easily than intact skin)
• Increased facility length of stay
• Undergoing surgery longer than four hours
• Significant weight loss
• Prolonged time on a stretcher (since the surface is not conducive to pressure relief)
• Emergency department stays
• Medications, such as sedatives, analgesics, and nonsteroidal anti-inflammatory drugs (NSAIDs)
• Impaired sensation
• Refusal of care, such as when a patient refuses to be turned or moved despite education
• Edema
• Obesity
• Patient not being turned
• An intensive care unit stay, due to the high acuity of illness, presence of multiple comorbid conditions, and:
  • Mechanical ventilation
  • Vasopressors and hemodynamic instability
  • Multiple surgeries
  • Increased length of stay
  • Inability to report discomfort
(WOCN, 2022a; Baranoski & Ayello, 2020)