Pressure Injury Management in CNS Disorders

Disease/Disorder

Definition

Pressure injury (PI) is defined as localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device.¹ The pressure injury stages and categories are described below.

• Stage 1 is an area of non-blanching erythema of intact skin.
• Stage 2 is a partial-thickness skin loss exposing the dermis.
• Stage 3 is a full-thickness skin loss.
• Stage 4 is a full-thickness skin loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone.
• An unstageable pressure injury is characterized by full-thickness skin and tissue loss whereby the extent of damage cannot be confirmed because the base is obscured by slough or eschar.
• A deep tissue injury (DTI) is intact or non-intact skin with persistent non-blanchable deep red or purple discoloration or bruising.

In 2016, the terminology of pressure ulcer was changed to pressure injury and specific pressure injury definitions were added and have been incorporated into current guidelines. Medical device related pressure injury describes the etiology of the injury and should follow the above classification system for staging. Mucosal membrane pressure injury describes injury due to use of medical device at the location of mucous membranes and cannot be staged according to the above classification system.¹

Etiology

Pressure injuries occur from intense and/or prolonged pressure, or from pressure in combination with shear. An external mechanical load causes axial pressure and shear force, leading to the body’s internal response and formation of the pressure injury. Pressure injuries can form immediately from the time of external load or up to several days after the insult. Shear stress has two deleterious effects: first, it can cause deep tissue deformation and necrosis; second, it can lead to superficial friction to the stratum corneum, damaging the barrier function. Pressure injuries can develop on the buttocks, coccyx, sacrum, ischia, trochanters, occiput, heels and other bony prominences.

Epidemiology including risk factors and primary prevention

Pressure injuries affect millions of individuals in the US each year, in various settings including acute care, long-term care, and the home. Complications can be very serious, including localized infection, sepsis, and death. Pressure injuries have a large impact on the health care system, with total annual costs in the billions.² Among people with spinal cord injuries (SCI), diseases of the skin accounted for rehospitalization rates from 11.5% up to 22.6%, the rate increasing each additional year post-injury.³

Risk factors for pressure injuries include pressure, shearing forces, impaired mobility, skin moisture, malnutrition, diminished capillary perfusion, and aging.² Pressure injuries are also associated with dementia, critical illness, pain, immobility, diabetes, atherosclerosis, end-stage renal disease, medications (steroids, immune-suppressants), smoking, upper or lower motor neuron disease, contractures, and non-adherence to treatments.²

Populations that are at a high risk for pressure injury development include people with spinal cord injuries, patients with critical illness, and older adults. For community-dwelling older adults, the incidence increases significantly with advancing patient age.⁴ For critically ill patients, increased risk of pressure injury was associated with diabetes, mechanical ventilation, and vasopressors.⁵ The absence of protective sensation increases the risk of pressure injury, such as from SCI or other neurologic conditions. From SCI model systems data, the prevalence of pressure injury increases in time post-injury, from 25.3% during the first-year post-injury, to 35.8% forty-five years post-injury.⁶

Other risk factors may include improper seating and sleeping surfaces, cushion or mattress malfunction, incomplete skin clearance during transfers, prolonged travel limiting pressure releases, and any other equipment malfunction.

Patho-anatomy/physiology

The skin is the largest organ in the body, composed of three layers: (1) epidermis, the outermost layer of the skin; (2) dermis, the layer beneath the epidermis, composed of connective tissue, glands, and follicles; and (3) the subcutaneous deeper layer (hypodermis), made up of fat and connective tissue.

One can think of pressure injury formation in two ways: forming “top-down” and “bottom-up.” Top-down formation involves pressure and shear damaging surface skin and the upper few millimeters of the sub-cutaneous layer. Bottom-up formation usually occurs with DTI. Sustained strain of the muscles between the external load and a bony prominence leads to damage to the deep tissues beneath the skin surface and forms the DTI.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

From the “top-down,” pressure injuries can form when an external mechanical load or pressure is applied on or against the skin, so that blood flow is compromised to that area. Initially, after short periods of pressure there is reversible damage to the skin which is manifested as blanching erythema. However, once the erythema is non-blanching, localized tissue damage has occurred, leading to the formation of a Stage 1 pressure injury. Depending on the depth and severity of the tissue damage, a pressure injury can present as a Stage 2, Stage 3, or Stage 4 injury. Another presentation is a DTI, described below.

For DTIs, disease progression generally manifests when pressure is applied over a bony prominence, causing compression in the deep or underlying tissues. Initially or within a few days there is non-blanching erythema seen as red-purple or dark-maroon rather than pink-red. Next, there is often sloughing and blistering of the surface, with a darker base, and demarcation of black or yellow eschar. DTI can be a marker of pre-terminal status. “Skin failure” is a phenomenon where DTI forms with greater frequency and severity near death.⁷

For pressure injuries secondary to medical devices, the resultant pressure injury usually follows the pressure pattern from the device in question. Ongoing research has started to identify risk factors specific for medical-device related pressure injuries-including length of time device is used, usage of subglottic suction catheter, and prone position ventilation.⁸ Mucosal membrane pressure injuries cannot be staged due to the anatomy of these tissues.¹

Specific secondary or associated conditions and complications

Secondary conditions and associated complications of pressure injuries are varied, including associated infection, osteomyelitis, cellulitis and possibly sepsis. Other secondary conditions include chronic pain, non-healing wounds, septic arthritis, fistula formation, anemia, and in severe cases, death or the need for limb amputation.² Pressure injuries can erode into joint capsules causing septic arthritis. Common bacteria implicated in pressure injury infection include Staphylococcus aureus, Pseudomonas aeruginosa, Proteus mirabilis, Klebsiella pneumoniae, Enterococcus spp., and Escherichia coli and many hospital-acquired pressure injuries can be linked to drug resistant bacteria.⁹ Ischial pressure injuries can form fistulae to the rectum or bladder. Pressure injuries of the heel, if Stage 4, may lead to ischemia, infection and/or ultimately limb loss.

Essentials of Assessment

History

The clinical interview and history are key in the assessment of pressure injury.

• When did the patient notice the skin changes and pressure injury?
• Did it occur after a specific inciting event, trauma, or fall?
• Has the individual experienced a change in their mobility and/or functional status?
• Has the individual been limited to bedrest?
• Which dressings, topical ointments or antibiotics have been used?
• Does the patient have sensation or complain of any discomfort in the area?
• Has the patient experienced any weight changes or weight loss?
• Have there been any equipment (i.e., bed, mattress, wheelchair cushion) malfunctions?
• Is the patient unable to communicate the problem due to speech or memory deficit?
• Does the patient receive assistance? If so, from who and for how many hours?
• What is the nutritional status of the patient?

Physical examination

For the general physical exam: evaluate body habitus and nutritional status. Note if the individual appears thin, pallid, frail, or chronically ill. Assess for weight loss, Body Mass Index (BMI), contractures, muscle strength, range of motion, memory and cognitive deficits, pedal pulses, and sensory impairments.

It is important to do a thorough examination of the skin upon initial evaluation of the patient. For the pressure injury: examine skin with patient in side-lying or lateral decubitus position. Note exact location and side (right vs. left) if indicated. Wound length, width and depth are measured in centimeters. Measure depth at the deepest point in the wound bed. Evaluate for any tunneling or undermining “by the clock” (e.g., 4 centimeters of tunneling at 6 o’clock; with noon toward the head). Note color of the wound bed (i.e., beefy red, dusky pink, yellow or black necrotic). Assess the wound base itself for percentage of slough or necrotic tissue (i.e., scab or eschar).  Note any odor, drainage (quality and amount), palpable bone, rolled or thickened edges, and peri-wound skin status as well. Wounds typically appear as follows. The National Pressure Ulcer Advisory Panel provides the following illustrations of each pressure injury Stage.¹ Please refer to definitions of each Stage described above in the definition section.

Functional assessment

Watch for impaired bed mobility, weight shifts, transfers and ambulation. Assess for cognitive or communication deficits and be mindful of non-verbal signs of discomfort. Consider the location of the pressure injury as clues to formation:

• Sacral injuries: Supine positioning
• Coccygeal injuries: Supine positing or “sacral sitting” (i.e., slouching)
• Trochanteric injuries: Lateral decubitus position
• Ischial injuries: Sitting
• Heel or lateral ankle injuries: External rotation with lateral compression.
• Malleoli, fibular head, lateral forefoot injuries: Wheelchair leg rests, shoes, orthotics.
• Elbow injuries: Wheelchair armrests.
• Scapular injuries: Wheelchair backrests.
• Occipital injuries: Cervical collars, bed/pillow positioning.
• Medical device and mucosal membrane injuries: Examine trajectory or pressure pathway related to device or mucous membrane irritant (i.e., urinary catheter).

The location of a pressure injury is often multifactorial. However, the etiology of CNS disorder can provide insight on which locations are most likely to be impacted. Patients with spinal cord injuries typically experience pressure injuries at the sacrum (most common), heels, and ischium.¹⁰ In patients with traumatic brain injury and ischemic or hemorrhagic strokes, the sacrum was found to be the most common area for pressure injury within the first 30 days of injury.^11,12 Importantly, pressure injuries in children most commonly occur on the occiput, ears, and nose, due to differing pressure distribution compared to adults.¹³

Laboratory studies

Elevated white blood count (WBC) may indicate systemic infection or inflammation. C-reactive protein and erythrocyte sedimentation rate are non-specific inflammatory markers of osteomyelitis which can be used to guide response to treatment only. Other lab markers for underlying diseases may be helpful to assess secondary disease control (i.e., A1c for Diabetes).

There is no lab test that is both sensitive and specific for malnutrition.¹⁴ In the past, clinicians have used prealbumin and albumin as a reflection of nutritional status. Current practice is to perform a nutrition-focused physical examination (NFPE) to diagnose malnutrition. The subjective global assessment (SGA) is a well-validated tool for recognizing malnutrition, assessing nutritional status based on history and physical findings. The clinician’s history should assess weight loss in the last six months, dietary intake changes, comorbid disease states and related nutritional demands, functional capacity, and gastrointestinal symptoms. The exam should also evaluate for edema, muscle wasting, subcutaneous fat, and ascites.¹⁴

Newer studies have attempted to identify biomarkers associated with pressure injuries. The Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), calculated from fasting plasma glucose and insulin, is a novel serum index associated with pressure injury history in people with chronic spinal cord injury. In a cross-sectional, observation study of adults with chronic traumatic spinal cord injury, comparing a group of individuals without history of pressure injury with a group of those with history of pressure injury, the group with history of pressure injury demonstrated significantly higher HOMA-IR, which suggests higher insulin resistance and longer duration of injury.¹⁵

Imaging

• X-ray can help make the diagnosis of osteomyelitis if positive for bony erosion.
• MRI for osteomyelitis can localize the lesion anatomically and give information about acute vs. chronic infection.
• Consider bone scan when MRI is contraindicated.
• Consider vascular studies to assess peripheral arterial disease (PAD) and distal limb blood supply for heel ulcers.

Supplemental assessment tools

The Braden scale is a valid, reproducible measure, which quantifies pressure injury risk. The classical Braden scale involves six sub-scales, each with four levels. The sub-scales are: 1) Insensitivity; 2) Mobility; 3) Activity; 4) Nutrition; 5) Moisture; 6) Friction and shear. The overall scale ranges from 6 to 24, with the highest score indicating lowest risk. The Norton risk assessment tool has five sub-scales and is also valid.

The Medical Device-Related Pressure Injuries (MDRPI) screening specifically focuses on pressure injuries caused by devices such as masks, tubes, catheters, and splints.⁵ It involves daily, systematic skin assessments primarily focused around medical devices to detect early signs of injury.Effective screening includes timely device removal for inspection, assessing for skin integrity during routine care, and implementing preventive protocols to reduce risk.

A newer development is the Subepidermal Moisture (SEM) Measurement. This equips handheld scanners to detect elevated moisture levels in the skin and underlying tissues. This measurement tool can identify developing pressure injuries approximately 5 days before they are visible.¹⁶

Thermal imaging, or infrared thermography, is a non-invasive tool that can be used to detect early-stage pressure injuries by identifying temperature changes before obvious injury is visible on the skin. It provides a rapid, reliable assessment of deep-tissue damage, aids in preventing injury progression, and can reduce clinical and financial burdens of hospital-acquired pressure injuries. Ultrasound-based deep tissue evaluation can similarly be equipped to augment skin assessment instead of just visual assessment alone.¹⁷

Early predictions of outcomes

Predictors of good outcomes for pressure injury are maintaining good nutrition, diligence with treatment regimen, pressure off-loading, optimal seating and mattress surfaces for skin protection, control of secondary medical conditions, and compliance from the patient and caregiver with the treatment plan.

• Stage 1 pressure injuries often resolve within days to weeks.
• Stage 2 pressure injuries generally heal within weeks.
• Stage 3 pressure injuries may take weeks to months
• Stage 4 injuries may require 6-12 months to conservatively close.

Environmental

Assess pressure support surfaces: bed, wheelchair, cushion, and lift/sling mechanisms used for transfers.

Ask about recliner use: recliners are associated with pressure injury formation of the sacrum, as turning and positioning are difficult, and positioning often enables sacral sitting.

Evaluate caregiver support and assistance available for skin prevention and prevention off-loading techniques.

Professional issues

All members of the rehabilitation team play a key role in the management of pressure injuries: nursing (health promotion and teaching, bowel and bladder management, wound care), physical therapy (mobility and equipment review), occupational therapy (self-care, equipment review), speech-language pathology (cognition, carryover, mental status), clinical dietician or nutritionist (calorie and protein assessment, monitor nutritional status), and psychologist (emotional adjustment). Physical and occupational therapists can also utilize pressure mapping in high-risk individuals to identify which pressure redistribution surface would work best for the specific patient, and then recommend the best suited pressure-relieving medical equipment, accordingly.²

For specialty wound care treatment and recommendations, consult a wound care specialist if available. Consult infectious disease for osteomyelitis; consider a surgical team for debridement or flap surgery; consider podiatry or vascular surgery for a heel pressure injury.

Rehabilitation Management and Treatments

Available or current treatment guidelines

Pressure injury care has the benefit of several excellent guidelines over the years for prevention and management. Two highly recommended guidelines include the National Pressure Ulcer Advisory Panel guidelines from 2025 and the Consortium for Spinal Cord Medicine Clinical Practice Guidelines from 2014.¹⁸

In 2025, the National Pressure Injury Advisory Panel (NPIAP), European Pressure Ulcer Advisory Panel (EPUAP), and Pan Pacific Pressure Injury Alliance (PPPIA) published the fourth edition of the International Pressure Injury Guideline¹. This includes a structured three-step risk process that involves screening, full assessment, and prevention plan, placing a higher emphasis on clinical judgment and considering the use of artificial intelligence or machine learning tools to supplement.

In these updated guidelines, medical devices are treated as a standalone risk factor, placing a focus on device-related pressure injuries. A patient is at risk as soon as a device is placed. Repositioning on a timely schedule is emphasized, especially utilizing micromovement in critically ill patients.

New recommendations for support surfaces place a strong favor for pressure distribution foam mattress, clarifying when to use air foam versus specialty surfaces. Specific preventative dressings are more clearly recommended such as soft silicone foam dressings for the sacrum and heels, and now with a larger focus shifting to placing preventative dressing under medical devices.

Detailed guidance on nutrition now directs clinicians to not use tube feeding solely to prevent pressure injuries. Targeted supplementation should only be used when needed. Technologic integration is mentioned, such as utilizing sensor systems for repositioning monitoring as well.

At different disease stages

• As a pressure injury heals, it continues to be referred to by the stage at which it initially presented.
• If wound debridement is needed, providers may use chemical or enzymatic debridement with collagenase. Sharp debridement can also be performed with pickups, scissors, curette, or scalpel. To reduce discomfort for sensate patients, pre-medicate, using topical anesthesia and offer “time out” and redirection during the procedure.
• Consider podiatry consult for unstageable or Stage 4 of the heel. If heel eschar is present, leave in place until appropriate surgical debridement can take place. Steps to preserve the limb include 1) revascularization; 2) appropriate surgical debridement; 3) antibiotics for osteomyelitis; 4) consideration of hyperbaric oxygen for osteomyelitis.¹
• Consider negative pressure wound therapy (NPWT or wound vacuum therapy) for Stage 3 or 4 injuries. Indication: when the pressure injury is debrided to about an 80% red base, wound bed is clean and free of acute infection. Purpose: promote granulation tissue formation.¹⁰ Endpoint: Granulation tissue fills most of the “dead space.” Contraindications: Untreated cellulitis, osteomyelitis, or exposed artery.
• For Stage 3-4 pressure injuries in persons with SCI, reconstructive surgery might be the best option and should be considered.
• Nutritional requirements can vary for each individual patient. Consultation with clinical dietician or nutritionist is key to assess average caloric needs and optimize nutrition for wound healing. Consider vitamin and mineral supplementation including Vitamin C and Zinc.
• Wound dressings can vary by pressure injury stage.
• For Stage 1 injuries, protective dressings can provide adequate cushioning.
• For Stage 2 or shallow Stage 3 injuries with scant to minimal drainage foams or films, zinc oxide paste (which is relatively imperious to moisture and shear) or barrier creams are often sufficient.
• For Stage 3-4 injuries with moderate or significant drainage consider alginate or absorptive dressings.

At all disease stages

Pressure injuries should be assessed at least weekly. Key assessments include length, width, depth, undermining, tunneling, drainage, odor, and peri-wound skin status. Evaluation with serial photographs is best if available and if compliant with patient privacy regulations. Assessments are graphed versus time to illustrate healing rate and progression. If the pressure injury does not show improvement in 2-3 weeks with the current treatment regimen, consider therapeutic change.

Wheelchair and cushions: Patients with stage 3 or 4 ischial pressure injuries, especially if insensate, should limit sitting as much as possible (if not completely) while pressure injuries are healing. Of course, the benefits of pressure off-loading must be balanced against potential risks (i.e., depression, social isolation, quality of life). One should consider a tilt-in-space wheelchair with a custom seating cushion system and appropriate leg rests for patients with pressure injuries greater than Stage 2-4 who require assistance with pressure off-loading. Providers should also consider pressure mapping in these patients.

Specialty bed: For stage 1 and 2 pressure injuries, a foam or air overlay is often enough. For the patient with a stage 3 or 4 sacral pressure injury, a low air loss or dynamic pressure relief mattress is appropriate. Current clinical guidelines based on expert consensus and clinician experience recommend turn and reposition every two hours.¹

The use of heel protector boots has been controversial in preventing pressure injuries, but recent data has found them to be protective in preventing the development of heel pressure injuries in intensive care unit patients.¹⁹

Cutting Edge/Emerging and Unique Concepts and Practice

There are many emerging treatment practices in the field of pressure injury management, including but not limited to the following:

• Electrical Stimulation (ES) has been shown to be beneficial in the healing of pressure injuries. Electrodes are placed on the skin, which provide electrical current to the treatment area, either with direct or pulsed current. There are many theories of how ES affects the inflammatory, proliferative, epithelialization, and remodeling phases of healing of PIs, including by increasing blood flow to the area and increasing tissue oxygenation. There is some thought that ES can also provide a bacteriostatic effect.¹⁰
• Hyperbaric Oxygen (HBO) has been used for various skin conditions, including diabetic ulcers, vascular ulcers, and pressure injuries. While hyperbaric oxygen has been used to treat hard to heal wounds, there is a lack of evidence for the use of hyperbaric oxygen on pressure injuries specifically.¹⁰
• Bone marrow/autologous stem cells use live cells to try to repair or restore the damaged tissue area of the wound bed. The bone marrow or stem cells are thought to recruit macrophages and endothelial cells to the wound bed, enhancing wound healing by preventing apoptosis, promoting angiogenesis, and assisting in wound matrix reorganization. It is a newer therapy but has demonstrated efficacy in healing skin wounds and sores.¹⁰
• Bio-engineered skin, or skin substitutes, had been used for treatment of wounds, particularly in partial or full-thickness wounds as biological wound dressings. It is thought that this modality induces angiogenesis. Limitations of this therapy include difficulties in application due to amounts of exudate in the wound bed and/or external forces that prevent graft adherence.¹⁰
• Cytokines and growth factors are thought to affect the inflammation, collagen matrix structure, apoptosis, and rate of healing of wounds. Some examples include fibroblast growth factor, granulocyte-macrophage colony-stimulating factor, interleukins, tumor necrosis factor, and endothelial growth factor. These substances may have an integral role in the treatment of pressure injuries in the future.
• Artificial intelligence is emerging mainly for risk prediction, image-based assessment, and decision support.²⁰
• The 2023 Wound Healing Society guidelines highlight formal nutritional assessment and recommend targets of 30–35 kcal/kg/day and 1.25–1.50 g protein/kg/day when intake is insufficient, if aligning with care goals. Arginine-containing, disease-specific supplements are gaining attention, though their benefits are adjunctive rather than curative.²¹
• New data has shown that differing composition of the microbiome of a pressure injury can affect healing rates. Interventions targeting the specific microbiome, such as debridement and platelet-rich plasma therapy, are up-and-coming therapies with promising data.⁹

Gaps in the Evidence-Based Knowledge

The knowledge and science of pressure injury assessment, treatment, and prevention is constantly evolving. Current gaps in the clinical care of individuals with pressure injuries are varied.

• Guidelines need to be based on thorough and comprehensive review of available literature and rigorous research methods.
• There are no clear guidelines for mucosal membrane pressure injury staging and they cannot be staged using standard Stage 1-4 systems. Clear staging definitions of this type of pressure injury can better guide effective management depending on the severity.²²
• Unique characteristics of individuals with CNS disorders must be considered.
• Clinicians need to stay updated with new terminology and definitions, Staging, and prevention strategies as they are identified in the literature and by professional organizations.
• There is ongoing research into how often patients need to be repositioned in order to minimize the development of pressure injuries. New studies have challenged the current clinical practice to reposition all patients every 2 hours, and have introduced the idea that the repositioning time may be individualized based on patient-specific factors².
• Evidence-based research must continue forward in the emerging concepts and practices described above, as well as with any new therapies discovered, in order to identify beneficial treatments and interventions for pressure injuries.
• Research and patient care must be created and carried out in an interdisciplinary framework in order to achieve the greatest success in skin prevention and treatment.

References

1. NPIAP/EPUAP/PPPIA. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. 2025. Accessed October 2025. Available at: https://internationalguideline.com/the-international-guideline
2. Peterson A, Fraix MP, Agrawal DK. Preventing pressure injuries in individuals with impaired mobility: Best practices and future directions. J Surg Res (Houst). 2025;8(3):319-334. doi:10.26502/jsr.10020455
3. 2024 Annual Statistical Report Complete Public Version for the Spinal Cord Injury Model Systems. NSCISC National Spinal Cord Injury Statistical Center. August 2025. Accessed March 26, 2026. https://sites.uab.edu/nscisc/.
4. Zhang S, Wei G, Han L, Zhong W, Lu Z, Niu Z. Global, regional and national burden of decubitus ulcers in 204 countries and territories from 1990 to 2021: a systematic analysis based on the global burden of disease study 2021. Front Public Health. 2025;13:1494229. Published 2025 Feb 26. doi:10.3389/fpubh.2025.1494229
5. Lee H, Choi S. Protocols and their effects for medical device-related pressure injury prevention among critically ill patients: a systematic review. BMC Nurs. 2024;23(1):403. Published 2024 Jun 17. doi:10.1186/s12912-024-02080-y
6. National Spinal Cord Injury Statistical Center. 2019 Annual Statistical Report for the Spinal Cord Injury Model Systems, www.nscisc.uab.edu
7. Levine, Jeffrey M. MD, AGSF, CMD, CWS-P; Delmore, Barbara PhD, RN, CWCN, MAPWCA, IIWCC-NYU, FAAN; Cox, Jill PhD, RN, APN-c, CWOCN, FAAN. Skin Failure: Concept Review and Proposed Model. Advances in Skin & Wound Care 35(3):p 139-148, March 2022. | DOI: 10.1097/01.ASW.0000818572.31307.7b
8. Gou L, Zhang Z, A. Y (2023) Risk factors for medical device-related pressure injury in ICU patients: A systematic review and meta-analysis. PLOS ONE 18(6): e0287326. https://doi.org/10.1371/journal.pone.0287326
9. Schmandt C, Llukovi E, Capossela S, et al. The association between pressure injury microbiome and wound healing: a systematic review. Front Cell Infect Microbiol. 2026;15:1703418. Published 2026 Jan 8. doi:10.3389/fcimb.2025.1703418
10. Vecin NM, Gater DR. Pressure Injuries and Management after Spinal Cord Injury. J Pers Med. 2022;12(7):1130. Published 2022 Jul 12. doi:10.3390/jpm12071130
11. Osis, SL, & Diccini, S. Incidence and risk factors associated with pressure injury in patients with traumatic brain injury. International Journal of Nursing Practice. 2020; 26(3).
12. Farid, J, Amin, R, Sheikh, MA, et al. Prevalence and prediction of pressure ulcers in admitted stroke patients in a tertiary care hospital. Journal of Tissue Viability. 2022; 31(3).
13. Hongyan Zhang, Yuxia Ma, Qing Wang, Xiujuan Zhang, Lin Han, Incidence and prevalence of pressure injuries in children patients: A systematic review and meta-analysis, Journal of Tissue Viability, Volume 31, Issue 1, 2022,
14. Munoz, Nancy DNC, MHA, RDN, FAND; Posthauer, Mary Ellen RDN, LD, FAND; Cereda, Emanuele MD, PhD; Schols, Jos M. G. A. MD, PhD; Haesler, Emily PhD, BN, P Grad Dip Adv Nurs. The Role of Nutrition for Pressure Injury Prevention and Healing: The 2019 International Clinical Practice Guideline Recommendations. Advances in Skin & Wound Care 33(3):p 123-136, March 2020. | DOI: 10.1097/01.ASW.0000653144.90739.ad
15. Tzen YT, Champagne PT, Wang J, et al. Markers for Pressure Injury Risk in Individuals with Chronic Spinal Cord Injury: A Pilot Study. Adv Skin Wound Care. 2025;38(2):E12-E17. doi:10.1097/ASW.0000000000000253
16. Budri AMV, Moore Z, Patton D, O’Connor T, Nugent L, Avsar P. Sub-epidermal moisture measurement: an evidence-based approach to the assessment for early evidence of pressure ulcer presence. Int Wound J. 2020 Dec;17(6):1615-1623. doi: 10.1111/iwj.13437. Epub 2020 Jul 19. PMID: 32683789; PMCID: PMC7948609.
17. Koerner S, Adams D, Harper SL, Black JM, Langemo DK. Use of Thermal Imaging to Identify Deep-Tissue Pressure Injury on Admission Reduces Clinical and Financial Burdens of Hospital-Acquired Pressure Injuries. Adv Skin Wound Care. 2019 Jul;32(7):312-320. doi: 10.1097/01.ASW.0000559613.83195.f9. PMID: 31192867; PMCID: PMC6716560.
18. Garber S, Bryce T, et al. Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Paralyzed Veterans of America. Second Edition. 2014.
19. Arslan K, Ates S. The effects of using heel protectors on the prevention of heel pressure injuries and plantar flexion contractures. Nurs Crit Care. 2024;29(6):1729-1738. doi:10.1111/nicc.13071
20. Alves J, Azevedo R, Marques A, Encarnação R, Alves P. Pressure Injury Prediction in Intensive Care Units Using Artificial Intelligence: A Scoping Review. Nurs Rep. 2025;15(4):126. Published 2025 Apr 9. doi:10.3390/nursrep15040126
21. Gould LJ, Alderden J, Aslam R, et al. WHS guidelines for the treatment of pressure ulcers-2023 update. Wound Repair Regen. 2024;32(1):6-33. doi:10.1111/wrr.13130
22. Velozo BC, Hong MV, Bernardo LC, E Castro MCN, Contreras-Ruiz J, Abbade LPF. Pressure injury: update on general concepts, clinical aspects, and laboratory findings – Part I. An Bras Dermatol. 2025;100(5):501187. doi:10.1016/j.abd.2025.501187

Original Version of the Topic:

Scott Campea, MD. Pressure Ulcer Management. 11/15/2011

Previous Revision(s) of the Topic:

Robert J. Goldman, MD. Pressure Ulcer Management. 9/20/2013

Sarah Wagers, MD, Preeti Panchang, MD. Pressure Ulcer Management. 5/05/2016

Juan L Asanza, MD. Pressure Injury Management in CNS Disorders. 10/29/2019

Juan L Asanza, MD, Hetal Patel, MD. Pressure Injury Management in CNS Disorders. 7/13/2023

Author Disclose

Hannah Ariel Levine, MD
Nothing to Disclose

Kerstin Yu, MD
Nothing to Disclose

Brandon Kase, MD, MBA
Nothing to Disclose