Risk assessment | Wounds Africa

Identifying patients who are at high risk for developing pressure injuries

There is a slight overlap between this and the last chapter. However, in this chapter, we will look more closely at the tools we have to do a standardized risk assessment for developing pressure injuries. Again, the goal is to identify which patients we need to invest more resources in to prevent pressure injuries. Remember: it is quite easy to prevent pressure injuries - it is very difficult to treat them. Previously, many caregivers assumed that pressure injuries were just something some people developed. Today, we are quite rigid and strict on this matter. If the pressure injury happened on your watch or in your department, you are to blame for that pressure injury! This way of thinking has transpired into the judicial system of many Western countries, where individual caregivers and institutions are now being sued by patients if pressure injuries happen!

There are many ways to define a patient's risk category for developing a pressure injury. The simplest method is to categorize the patient as either having a high risk or no risk at all. We at WoundsAfrica like to keep things simple and find that this basic assessment is enough for most settings. Either the patient is at risk, or they are not.

Other scales are more detailed, dividing patients into no-risk, intermediate-risk, or high-risk groups. If you are in doubt about the risk, you always place the patient in the safest category for them. If you are unsure whether the patient is at intermediate or high risk, place them in the high-risk group.

The following is a list of common high-risk factors for developing pressure injuries.

Wheelchair-bound or bedridden and unable to change position without assistance

Nerve damage from injury or illness, and are unable to sense pain or the signals that typically make people shift position ( traumatic spinal injury, spina bifida, diabetes, stroke)

Patients who have undergone major surgery, resulting in them lying supine for a long time.

Patients who are intubated (intensive care unit)

Patients who have previously had pressure ulcers

Poor nutritional status /dehydration

Overweight

Hip fractures in the elderly ( or other major orthopedic fractures in the elderly)

Surgical procedures that last more than 3 hours
Alcoholism/drug abuse

Cardiac - or renal insufficiency, anemia

Patients with cognitive changes ( dementia or psychological changes)

Incontinence, especially incontinence-associated dermatitis (IAD)

Patients with dark skin ( more difficult to detect early warning signs of pressure injury developing, and more difficult to detect redness in the skin in people with dark skin)

Patients with cortisone-related skin degeneration (i.e., patients who use corticosteroids for KOLS or rheumatism)

Dry and thin skin due to other conditions

Patients with poor arterial circulation

Use of catheters, tubes, orthotics/plaster of Paris

Sometimes it is very obvious that a patient is at high risk, and at other times it may not be as apparent. Therefore, it is often helpful to use a standardized tool to aid our decision-making. The first and probably most well-known scoring tool was developed by Norton in 1962. It was initially designed for identifying patients at risk in older people's homes.

Since then, many different scoring tools and scales have been developed. Some of the more well-known tools include the Grosnells scale (1973) and Waterlow (1985). In recent years, the Purpose-T tool has been introduced in the NHS in the UK. Another popular scoring tool is the Braden scale (1987), used primarily in the USA. The multitude of scoring tools available tells you one thing: none of these tools fulfill all needs or are perfect - the best scoring tool has not yet been designed!

Most of the tools have in common that they examine some risk factors and assign a point value to each. Remember - a risk assessment tool cannot cover all bases - you will always have to rely on your evaluation of the patient as well.

WoundsAfrica`s simple pressure injury risk evaluation tool:

We do not think we can claim fame for the simplest of all tools - three simple questions about the patient. Suppose you can answer yes to one or more of the questions. In that case, the patient is at high risk of developing a pressure injury or already has one upon examination. You may think that this tool is over-simplified. In reality, it is not. If every health care worker screened patients with this very simple screening tool, we would have made significant progress in preventing pressure injuries globally.

Table 1: In most situations, this very simple screening tool is sufficient to identify patients where we need to be very vigilant and ensure that all risk areas are adequately offloaded and inspected regularly. Critics of such a simplified risk assessment tool say that it does not consider nutrition, skin condition, and age specifically, but all these factors are combined into the third question.

The advantage of the very simple risk assessment tool above is that it is super simple to remember - possibly increasing the chance that it is actually used. If your workplace has not previously used a risk assessment tool, we advise you to start with the simple tool. If your colleagues do not use the tool, you can be sure that introducing a more complex tool, such as the Norton or Braden scale, will waste your time. A disadvantage of using a very simple tool is that it does not allow you to differentiate between the patient's risk of developing pressure injuries as medium or high. But does this really matter? Do we treat medium-risk patients very differently from high-risk patients? We think not.

In departments where pressure injury prevention is well-implemented, we advise you to use a more detailed risk assessment tool. WoundsAfrica prefers the Norton scale, but others may favor the Braden scale or another tool. In the past years, the Purpose - T tool has been introduced in the NHS in the UK and is widely accepted there. Take a look at them and choose the one that best fits your department's needs. Remember: the more complicated your tool is, the less likely it is to be used. If you plan to conduct research on pressure-related injuries, it is essential that you choose the tool best suited for your study. Review similar studies to identify which risk assessment tools they used. It will be a shame if your research is being criticized because you used a risk assessment tool that did not correlate with what you wanted to find out. For example, if you were to study the risks of moisture-associated skin damage in the development of pressure ulcers, the Braden score would be more suitable, as it includes a more detailed category on moisture.

Purpose-T Risk Assessment Tool

PURPOSE-T is very much a “UK-grown” evolution in pressure ulcer risk assessment, and it is increasingly embedded in NHS practice, replacing older tools in many trusts. It was developed by the University of Leeds, and the latest version (version 2) was published and validated in 2018.

The tool follows a three-step process. The initial screening stage enables clinicians to rapidly identify patients who are not at risk, thereby reducing unnecessary workload. Patients who are not excluded proceed to a full assessment, which considers a range of evidence-based risk factors, including mobility, skin status, perfusion, sensory perception, moisture, nutrition, and the presence of medical devices. Importantly, PURPOSE-T integrates skin assessment directly into the risk evaluation process, ensuring that early signs of pressure damage or existing ulcers are identified.

Rather than producing a numerical score, PURPOSE-T uses a decision-making pathway that categorizes patients into groups such as “not at risk,” “at risk,” or “has existing pressure ulcer or scarring.” This approach encourages clinicians to use structured clinical judgment rather than relying on arbitrary cut-off values. As a result, the tool supports more individualized care planning and reduces the risk of false reassurance that can occur with low numerical scores in traditional systems.

One of PURPOSE-T's key strengths is its emphasis on clinical reasoning. The tool is designed to support, rather than replace, professional judgment, allowing clinicians to consider the broader clinical context when making decisions. In addition, by explicitly distinguishing between primary and secondary prevention, PURPOSE-T facilitates clearer care pathways and more appropriate allocation of preventive and therapeutic interventions.

Compared with traditional tools such as the Braden or Norton scales, PURPOSE-T represents a shift away from score-based risk stratification toward a more holistic, decision-oriented model. While this may require a period of adjustment for clinicians accustomed to numerical scoring systems, it offers significant advantages in terms of clinical relevance, patient safety, and alignment with modern evidence-based practice.

Image 1: The Purpose-T risk assessment tool has been widely integrated in the NHS in the UK. The image above is obviously too small to read properly, but clicking it takes you to a manual on how to use the tool.

The Norton Scale: A Classic Tool for Pressure Ulcer Risk Assessment

The Norton Scale is one of the earliest and most widely recognized tools for assessing the risk of pressure ulcer development. It was developed in 1962 by Doreen Norton and colleagues at St Thomas’ Hospital in London, marking a significant step forward in the systematic evaluation of patients at risk of pressure damage. Despite its age, the Norton Scale remains in use in many healthcare settings and has influenced the development of numerous later risk assessment tools.

The scale is based on the assessment of five key domains: physical condition, mental state, activity, mobility, and incontinence. Each of these categories is scored on a scale from 1 to 4, with lower scores indicating greater impairment. The individual scores are then summed to produce a total score ranging from 5 to 20. A lower total score corresponds to a higher risk of pressure ulcer development, with commonly used thresholds identifying patients at risk when the score falls below a defined level, often 14 or less.

One of the main strengths of the Norton Scale is its simplicity. It is quick to perform, requires minimal training, and provides a clear numerical output that can be easily communicated between healthcare professionals. This ease of use has contributed to its widespread adoption and longevity in clinical practice. In addition, the scale encourages a structured assessment of key patient-related factors, helping standardize risk evaluation across care settings.

However, the simplicity of the Norton Scale is also one of its limitations. The tool includes relatively few risk factors and does not account for several variables now known to be important in pressure ulcer development, such as nutritional status, tissue perfusion, or the presence of medical devices. Furthermore, the use of a summed numerical score can lead to over-reliance on threshold values, potentially resulting in underestimating or overestimating risk in individual patients.

Compared with more modern tools such as PURPOSE-T, the Norton Scale represents an earlier, score-based approach to risk assessment. While PURPOSE-T emphasizes clinical judgment, integrates skin assessment, and distinguishes between primary and secondary prevention pathways, the Norton Scale focuses primarily on generating a numerical risk estimate. As a result, it may be less effective in guiding detailed clinical decision-making in complex patients.

Despite these limitations, the Norton Scale retains historical and practical importance. It laid the foundation for structured pressure ulcer risk assessment and remains valued in settings where a rapid, straightforward screening tool is needed. In some contexts, it is also used alongside clinical judgment or in combination with more comprehensive frameworks to support patient care.

In summary, the Norton Scale is a simple, historically significant tool that introduced a systematic approach to assessing pressure ulcer risk. While it has been largely superseded by more comprehensive and clinically nuanced models, it remains a useful and accessible method for initial risk screening and continues to influence contemporary practice.

Table 2 A modified ( simplified) version of the Norton scale. For further information and sources, where to download a printable. If you click on the table above, you will get to a printable version of this risk assessment tool.

This is how you interpret the results:

26-22 Points: Low Risk

21-17 Points: Middle Risk

16-11 Points: High Risk

10-00 Points: Very High Risk

The Braden Scale: A Widely Used Tool for Pressure Ulcer Risk Assessment

The Braden Scale is one of the most widely used tools for assessing the risk of pressure ulcer development in clinical practice. It was developed in 1987 by Barbara Braden and Nancy Bergstrom in the United States, with the aim of providing a more comprehensive and evidence-informed approach than earlier tools such as the Norton Scale. Since its introduction, it has been extensively validated and adopted internationally across a wide range of healthcare settings.

The Braden Scale assesses six key domains that contribute to pressure ulcer risk: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Each domain is scored on a scale of 1 to 4, except for friction and shear, which are scored on a scale of 1 to 3. The individual scores are summed to produce a total score ranging from 6 to 23, where lower scores indicate a higher level of risk. Commonly used thresholds classify patients as at mild, moderate, high, or very high risk, helping clinicians identify those who require preventive interventions.

One of the main strengths of the Braden Scale is its broader scope compared to earlier tools. By including factors such as nutrition and moisture, it reflects a more nuanced understanding of the mechanisms underlying pressure ulcer development. The scale is relatively straightforward to use, while still offering greater clinical detail than simpler tools. This balance between usability and comprehensiveness has contributed to its widespread acceptance and longevity.

In addition, the Braden Scale has been the subject of extensive research, demonstrating reasonable predictive validity across patient populations in acute care, long-term care, and community settings. Its structured format also facilitates communication among healthcare professionals and supports documentation, audit, and research activities.

However, the Braden Scale also has limitations. Like other numerical tools, it relies on summing scores across domains, which can obscure important clinical nuances. Patients with very different risk profiles may end up with similar total scores, potentially leading to inappropriate standardization of care. Furthermore, the scale does not explicitly account for certain factors now recognized as important, such as medical devices or detailed skin assessment findings. As a result, there is a risk that clinicians may rely too heavily on the total score rather than integrating clinical judgment.

Compared with more recent frameworks such as PURPOSE-T, the Braden Scale represents a more traditional, score-based approach to risk assessment. While PURPOSE-T emphasizes decision-making pathways, integrates skin status, and distinguishes between primary and secondary prevention, the Braden Scale focuses on quantifying risk through a numerical score. Nevertheless, the Braden Scale remains highly relevant, particularly in settings where standardization, ease of use, and comparability are important.

In summary, the Braden Scale is a well-established and extensively validated tool that provides a structured and relatively comprehensive method for assessing pressure ulcer risk. Although it has certain limitations and may be complemented by newer approaches, it continues to play a central role in clinical practice worldwide and remains a cornerstone of pressure ulcer prevention strategies.

Video 1: A video explaining how to use the Braden scale for pressure ulcer risk identification. Click on the image to start the video. Copyright:SCIREproject.com /YouTube

Table 3 The table shows the original Braden scale - we are sorry that the image above is hard to read - if you want to read it at a better resolution and need a printable pdf version, click on the image above.

This is how you interpret the results:

<9 Points: Very high risk

10-12 Points: High risk

13-14 Points: Moderate risk

15-18 Points: Low risk

References

Doreen Norton, McLaren R, Exton-Smith AN. An investigation of geriatric nursing problems in a hospital. London: National Corporation for the Care of Old People; 1962.

Barbara Braden, Nancy Bergstrom. A conceptual schema for the study of the etiology of pressure sores. Rehabilitation Nursing. 1987;12(1):8–12.

Bergstrom N, Braden B, Laguzza A, Holman V. The Braden Scale for predicting pressure sore risk. Nursing Research. 1987;36(4):205–210.

Coleman S, Nixon J, Keen J, et al. A new pressure ulcer conceptual framework. Journal of Advanced Nursing. 2014;70(10):2222–2234.

Coleman S, Smith IL, Nixon J, et al. Pressure ulcer risk assessment using PURPOSE-T: a validation study. Journal of Advanced Nursing. 2018;74(2):407–418.

University of Leeds. PURPOSE-T User Manual (Version 2). Leeds: Leeds Institute of Clinical Trials Research; 2014.

National Institute for Health Research (NIHR). Pressure Ulcer Programme of Research (PURPOSE). UK; 2010–2018.

National Wound Care Strategy Programme. Pressure ulcer recommendations and pathways. NHS England; 2020–ongoing.

National Institute for Health and Care Excellence (NICE). Pressure ulcers: prevention and management (CG179). London: NICE; 2014 (updated guidance available online).

NHS Improvement. Pressure ulcer prevention: aSSKINg framework. NHS; various local and national publications.

Wounds UK. Best practice statements: pressure ulcer prevention and aSSKINg framework. London: Wounds UK; various editions.