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Int J Nurs Stud. 2017 Jun;71:97-114. doi: 10.1016/j.ijnurstu.2017.03.012. Epub 2017 Mar 28.

Risk factors for pressure injuries among critical care patients: A systematic review.

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Boise State University, 1910 W University Drive, Boise, Idaho 83725, United States; University of Utah College of Nursing, 10 2000 E, Salt Lake City, UT 84112, United States; St. Luke's Meridian Medical Center, 520 S Eagle Road, Meridian, Idaho 83642, United States. Electronic address:
Kaiser Permanente Southern California Health Services, 393 E Walnut Street 7th Floor, Pasadena, CA 91188, United States. Electronic address:
University of Utah College of Nursing, 10 2000 E, Salt Lake City, UT 84112, United States. Electronic address:
University of Utah College of Nursing, 10 2000 E, Salt Lake City, UT 84112, United States. Electronic address:
University of Washington, Box 357266, 1959 NE Pacific St., Seattle, WA 98195, United States. Electronic address:



To identify risk factors independently predictive of pressure injury (also known as pressure ulcer) development among critical-care patients.


We undertook a systematic review of primary research based on standardized criteria set forth by the Institute of Medicine.


We searched the following databases: CINAHL (EBSCOhost), the Cochrane Library (Wilson), Dissertations & Theses Global (ProQuest), PubMed (National Library of Medicine), and Scopus. There was no language restriction.


A research librarian coordinated the search strategy. Articles that potentially met inclusion criteria were screened by two investigators. Among the articles that met selection criteria, one investigator extracted data and a second investigator reviewed the data for accuracy. Based on a literature search, we developed a tool for assessing study quality using a combination of currently available tools and expert input. We used the method developed by Coleman et al. in 2014 to generate evidence tables and a summary narrative synthesis by domain and subdomain.


Of 1753 abstracts reviewed, 158 were identified as potentially eligible and 18 fulfilled eligibility criteria. Five studies were classified as high quality, two were moderate quality, nine were low quality, and two were of very low quality. Age, mobility/activity, perfusion, and vasopressor infusion emerged as important risk factors for pressure injury development, whereas results for risk categories that are theoretically important, including nutrition, and skin/pressure injury status, were mixed. Methodological limitations across studies limited the generalizability of the results, and future research is needed, particularly to evaluate risk conferred by altered nutrition and skin/pressure injury status, and to further elucidate the effects of perfusion-related variables.


Results underscore the importance of avoiding overinterpretation of a single study, and the importance of taking study quality into consideration when reviewing risk factors. Maximal pressure injury prevention efforts are particularly important among critical-care patients who are older, have altered mobility, experience poor perfusion, or who are receiving a vasopressor infusion.


Critical care; Pressure injury; Risk factor; Skin

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