Risk Factors

Risk factor	Considerations
Advanced age	Skin has less moisture and becomes more fragile as epidermal turnover slows, vascularization decreases, and skin layers adhere less securely to one another There is less elasticity and decreased barrier function. Older adults have less lean body mass and less subcutaneous tissue to cushion bony areas. Underlying problems that increase pressure injury risk include poor hydration and impaired respiratory and immune systems.
Immobility	Immobility may be the greatest risk factor for pressure injury development. The person may be less able to move in response to pressure sensations, and body position may be changed less frequently.
Incontinence	Incontinence increases a patient's exposure to moisture and, over time, increases risk of skin breakdown. Urinary and fecal incontinence together can result in excessive moisture and chemical irritation.
Infection	Compressed skin has a lower local resistance to bacterial infection. Infection may reduce the pressure needed to cause tissue necrosis.
Low blood pressure	Low blood pressure can lead to tissue ischemia, particularly in patients with vascular disorders. As tissue perfusion drops, the skin is less tolerant of sustained external pressure, increasing the risk of damage from ischemia.
Malnutrition	A strong correlation exists between poor nutrition and the development of pressure injury. The body requires increased protein for healing; malnutrition can lead to decreased protein levels, including decreased albumin. A direct correlation exists between pressure injury stage and the degree of hypoalbuminemia.

Pressure injuries in bariatric patients

Bariatric patients are at increased risk for pressure injury development for several reasons:

Their nutritional status might not be optimum.
They're prone to developing protein malnutrition during metabolic stress (even though they may have excess body fat storage).
Adipose tissue commonly has decreased vascularity.
They may be unable to change position or move independently easily.
The moist environment in skinfolds promotes bacterial growth, which can lead to fungal infections and decreased skin integrity.

Braden scale for predicting pressure sore risk

Tally the numbers for each subscale using the description that applies to your patient. Determine your patient's risk as follows:

15 to 18: At risk
13 to 14: Moderate risk
10 to 12: High risk
9 or below: Very high risk.

Sensory perception: Ability to respond meaningfully to pressure-related discomfort
*1. Completely limited* Unresponsive (does not moan, flinch, or grasp) to painful stimuli due to diminished level of consciousness or sedation OR Limited ability to feel pain over most of body	*2. Very limited* Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness. OR Has a sensory impairment which limits the ability to feel pain or discomfort over ½ of body.	*3. Slightly limited* Responds to verbal commands but cannot always communicate discomfort or the need to be turned. OR Has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.	*4. No impairment* Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.
Moisture: Degree to which skin is exposed to moisture
*1. Constantly moist* Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.	*2. Very moist* Skin is often, but not always moist. Linen must be changed at least once a shift.	*3. Occasionally moist* Skin is occasionally moist, requiring an extra linen change approximately once a day.	*4. Rarely moist* Skin is usually dry; linen only requires changing only at routine intervals.
Activity: Degree of physical activity
*1. Bedfast* Confined to bed.	*2. Chairfast* Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair.	*3. Walks occasionally* Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in a bed or chair.	*4. Walks frequently* Walks outside room at least twice a day and inside room at least once every two hours during waking hours.
Mobility: Ability to change and control body position
*1. Completely immobile* Does not make even slight changes in body or extremity position without assistance.	*2. Very limited* Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.	*3. Slightly limited* Makes frequent though slight changes in body or extremity position independently.	*4. No limitations* Makes major and frequent changes in position without assistance.
Nutrition: Usual food intake pattern
*1. Very poor* Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement. OR Is NPO and/or maintained on clear liquids or IVs for more than 5 days.	*2. Probably inadequate* Rarely eats a complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR Receives less than optimum amount of liquid diet or tube feeding.	*3. Adequate* Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered. OR Is on a tube feeding or TPN regimen which probably meets most of nutritional needs.	*4. Excellent* Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.
Friction and shear
*1. Problem* Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction.	*2. Potential problem* Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.	*3. No apparent problem* Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.	Total score

Copyright 1988. Barbara Braden and Nancy Bergstrom. Reprinted with permission. All rights reserved. Permission to use this tool in clinical practice may be obtained, usually free of charge, at www.bradenscale.com.

Norton scale

When to assess and reassess

How frequently you assess and reassess your patient for pressure injury risk will depend on the care setting. The Agency for Healthcare Research and Quality and the Wound, Ostomy, and Continence Nurses Society recommend the following intervals:

Acute care: Upon admission and then daily or when the patient's condition changes. Some critical care areas complete risk assessment every shift.
Long-term care: Upon admission and then weekly for the first 4 weeks, then monthly or whenever the patient's condition changes.
Home health care: Upon admission and at every nursing visit.

Take note

Pressure injury documentation

Most electronic health records have options that can be selected based on your patient assessment. Here are some criteria for pressure injury documentation that are included:

Body location
Stage
Size—length · width · depth in centimeters
Tissue type—granulation, slough, eschar
Color of wound base
Periwound skin
Presence of undermining, tunneling, sinus tracts
Exudate—amount and character
Odor
Pain
Signs of infection
Status—New, improved, unchanged, deteriorating
Once your assessment is complete, be sure to document interventions and patient response. Include the following:
Topical therapy
Pressure redistribution surface(s)
Positioning schedule
Nutrition plan
Moisture management if indicated
Pain management.

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