Assessment of risk of pressure ulcers development

Preventive measures should by applied in order to prevent the development of pressure ulcers. It may take days before any changes are visible on the patient’s skin. therefore, it is important to identify the person with higher risk and start with targeted preventive measures right away. The risk of developing pressure ulcers has to be assessed as soon as possible. It has to be done on a regular basis, especially as health status of the patient changes, after major surgeries or before the patient is released from the hospital, to make sure that all the persons involved on the healthcare process have all necessary information.

The questions listed below may be used to assess the status of individuals with a higher risk of pressure ulcers development.

  1. Are the person’s daily activities restricted in any way?
    0 – no or insignificant restrictions
    1 – mild restrictions
    2 – medium restrictions
    3 – severe restrictions
    4 – unable to perform any activity at all
  2. For the purpose of transfer or position change, are friction free aids used?
    0 – yes
    1 – yes, every other time on the average
    2 – no
  3. Does the person experience pressure lasting over 1.5 hour on the same skin area?
    0 – no
    1 – yes, once a day
    2 – dyes, twice or more times a day
  4. Does the person wish to move?
    0 – yes
    1 – yes, partly
    2 – no

High risk
Over 8 points, or 3-4 degree pressure ulcers

Medium risk
5-8 points, or 1-2 degree pressure ulcers

Low risk
1-4 points

No risk
0 points

Activity and position changes always matter – and not only to prevent pressure ulcers.

When moving or transferring the patient, friction-free equipment has to be applied. If not, there is a growing risk of pressure ulcers development.

Besides the above listed ones, there also are other causes of pressure ulcers. There are numerous internal causes of pressure ulcers development that are not described here. However, below you may find additional tools for the assessment of pressure ulcers risk.

Norton extended scale assesses eight areas: mental status, physical activity, mobility, food intake, fluid intake, incontinence and general health status. Maximum result is 28 and the persons with 20 or less are exposed to the risk of developing pressure ulcers.

RAPS/RAB assesses physical activity, mobility, degree of skin exposure to humidity, food intake, fluid intake, sensitivity, friction and shearing. Maximum result is 39 and the persons with 31 or less are exposed to the risk of developing pressure ulcers.

Braden scale assesses five various areas: sensory perception, humidity, activity, mobility, friction and shearing. If the result is 18 or less, the person is exposed to the risk of developing pressure ulcers.

Waterlow scale assesses nine areas: BMI (body mass index), incontinence, skin type, pharmacotherapy, duration of the surgery, neurological problems, mobility, on overview of nutrition quality, sex and age. The result of 10 or more indicates that the person is exposed to a higher risk of developing pressure ulcers.