Pressure Ulcer Prevention - Risk Assessment

Preventing pressure ulcer formation begins with a thorough examination of the patient in order to identify the risk factors for the individual, which then allows the clinician to implement effective prevention strategies.

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The adage “an ounce of prevention is worth a pound of cure” is most appropriate when applied to pressure injuries/ulcers.  Studies have shown that pressure ulcers (PU) increase the hospital length of stay approximately 8 days.[1]  Approximately 2.5 million persons in the US are affected by PUs each year, with the following cost statistics: “Pressure ulcers cost $9.1-$11.6 billion per year in the US. Cost of individual patient care ranges from $20,900 to 151,700 per pressure ulcer. Medicare estimated in 2007 that each pressure ulcer added $43,180 in costs to a hospital stay.”[2]

The prevention strategies that are advised for any patient at risk for the development of a PU have been extensively discussed in the NPUAP/EPUAP/PPPIA 2014 Guidelines for Interventions for Prevention and Treatment of Pressure Ulcers, available at[3]  Strategies include risk assessment, nutrition assessment and supplementation, repositioning and mobilization, use of appropriate support surfaces, and skin assessment and care.  Each of these strategies will be discussed in detail over the next few weeks.

The risks for developing a PU are numerous and include, but are not limited to, the following:

  • Immobility
  • Malnutrition
  • Inability to feed oneself
  • Dehydration
  • Decreased sensory perception
  • Urinary and fecal incontinence
  • Critical illness
  • Co-morbidities, e.g. diabetes
  • Spinal cord injury
  • Older age
  • Trauma

A standardized risk assessment tool is advised for each patient admitted to any health care facility at these specific times:  within 8 hours of admission (or at first home visit), periodically thereafter depending upon the patient’s acuity, and any time the patient’s condition changes significantly.  This also includes a comprehensive skin assessment and note of any skin damage that is present upon admission. The patient’s prevention plan should be based upon the individual factors identified by the assessment, and not on the total score of the assessment tool.  Critical elements of the risk assessment include the following:

Activity and mobility limitations Is the patient bedfast or confined to a wheelchair?  What impact does this have on the skin integrity at the weight-bearing bony prominences where PUs usually occur?

Skin status Are there pressure ulcers already present?  Stage I’s are at risk for becoming deeper wounds, and patients with an existing PU are at risk for developing additional PUs.  Is the skin thin and fragile due to medications?  Is the skin persistently moist due to incontinence, high fevers, or wound drainage?  What is the perfusion status of the skin, especially on high risk areas like the heels or malleoli?

Nutrition Are there indicators of poor nutrition?  (to be discussed later) Can the patient self-feed?  Is there adequate intake at each meal?  Are there religious or allergy restrictions to the patient’s diet?

Sensory perception Does the patient have focal or generalized sensory deficits (e.g. with diabetic neuropathy or spinal cord injury)?  Are there cognitive deficits that prevent the patient from reporting or responding to sensory deficits?

Hemotological measures Blood values that have been associated with PU development include alterations to urea and electrolytes (e.g., creatinine above 1 mg/dl), elevated C-reactive protein, lymphopenia, low albumin, and low hemoglobin.3

The three most commonly used risk assessment tools are the Braden Scale (, the Norton Scale (, and the Waterlow Scale (  While these tools are helpful for guiding and documenting assessment for PU risk in any setting, good clinical judgment is also required for effective prevention of PU formation, in any setting and for any patient. 


More information on patient and wound assessment may be found at the following:

Hamm RL.  Examination and evaluation of the patient with a wound.  In Hamm R (Ed), Text and Atlas of Wound Diagnosis and Treatment: 2nd edition.  New York: McGraw Hill Education.  2019, 67-97.  Available at

[1] Whitty A, McInnes, Bucknall T, et al.  The cost-effectiveness of a patient centered ulcer prevention care bundle: Findings from the INTACT cluster randomized trial.  International Journal of Nursing Studies.  Available at  Accessed September 13, 2019.

[2] Agency for Healthcare Research and Quality.  US Department of Health and Human Services.  Preventing Pressure Ulcers in Hospitals.  Available at Accessed September 13, 2019.

[3] National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Prevalence and Incidence – an extract from the Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 201

Rose Hamm

Physical Therapy, University of Southern California