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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 of this is to see who of the patients we have 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 now are being sued by patients if pressure injuries happen!


There are many ways to define which risk category a patient is in terms of 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 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. If you are in doubt about the risk, you always put the patient in the category which is safest for them - if you are in doubt whether the patient only is an intermediate risk or high risk -then 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 which last more than 3 hours

  • Alcoholism/drug abuse

  • Cardial - 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 - 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 has a high risk, and it may not be as apparent at other times. Therefore it is often helpful to use a standardized tool to aid us in our decisions. The first and probably most 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 known tools are the Grosnells scale (1973) and Waterlow (1985), mainly used 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 look at some of the risk factors and have a point system for each risk factor.  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 either has a high risk of developing pressure injury or already has a pressure injury upon examination. You may think that this tool is over-simplified. In reality, it is not. If every health care worker screened patients using this very simple screening tool, we would have come a long way in preventing pressure injuries globally. 

wounds africa simple risk PU.JPG

Table 1 In most situations, this very simple screening tool is sufficient to identify the patients where we have to be very vigilant and where we have to make sure 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 complicated tool like Norton or Braden scale will waste your time. A disadvantage of using a very simple tool is that it will not let you differentiate whether the patient is at medium or high risk of developing pressure injuries. 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 a well-implemented routine, we advise you to use a more detailed risk assessment tool.  WoundsAfrica prefers the Norton scale, but others will argue favorably for the Braden scale or another tool.  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 will be used. If you are planning on doing research on pressure-related injuries, it is essential that you choose the tool best suited for your study. Look at other similar studies to see 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 do a study on the risks of moisture-associated skin damage for developing pressure ulcers, the Braden score would be more suitable as it has a more detailed category concerning moisture. 


wounds Africa norton scale.JPG

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

wounds africa braden scale.JPG

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 Poeng: High risk

13-14 Poeng: Moderate risk

15-18 Poeng: Low risk

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