Introduction

A pressure injury (PI) is defined as a localized injury to the skin and/or underlying tissues caused by pressure either alone or in combination with shear.¹ Hospitalized patients worldwide frequently present with PIs,² and these injuries can lead to prolonged hospital stays, increased medical expenses, and decreased quality of life.¹ Often, the injuries can be preventable, and the use of a structured, validated risk assessment tool is an important initial step in PI prevention.¹

Pressure Injury Risk Factors: Understanding the Impact

Risk factors for PI development are the basis of PI risk assessment tools. The most common PI risk factors include:¹

• Immobility
• Malnutrition
• Skin status
• Perfusion and oxygenation
• Moisture
• Sensory perception limitations (neuropathy)
• Blood markers (eg, elevated C-reactive protein [CRP], low hemoglobin, or low albumin)
• General health status

Individuals with comorbidities that correlate with these or other risk factors tend to be at higher risk of PIs. These comorbidities can include:

• Diabetes
• Vascular disease
• Obesity
• Incontinence
• Spinal cord injury (SCI)
• Traumatic injury

For example, patients with mobility limitations (eg, SCI or traumatic injuries) may be unable to shift their position to reduce the load on bony prominences. Conversely, individuals with sensory deficits (eg, diabetic neuropathy or SCI) may not feel pain associated with increased pressure and will continue to load that area. Individuals with moist skin, including those with incontinence or excess skin folds, are at more significant PI risk given their a greater vulnerability to friction, which can potentially result in greater shear damage.¹ In addition, occlusion resulting from the use of incontinence aids can alter the microclimate of the skin, and indwelling catheters pose a risk of medical-device related PIs. Furthermore, nutrition plays a vital role in the promotion of skin integrity and the support of tissue repair in the setting of PIs.³

Pressure Injury Screening Versus Full Risk Assessment: Timing and Goals

Before using a risk assessment tool, PI risk screening should be conducted as soon as possible after a patient is admitted and after any change in a patient’s status. The purpose of this screening is to rapidly identify individuals at high risk of PI development. A full risk assessment aims to thoroughly evaluate major risk factors as well as condition-specific risk factors for PI development. The assessment may also include risk assessment tools.

Pressure Injury Risk Assessment Tools

There are more than 50 scales available to assess patients at risk of PIs.⁴ The most widely used tools include:

• The Braden Scale
• The Norton Scale
• The Waterlow Scale
• The Cubbin-Jackson Scale

Although risk assessment tools provide a structure to guide PI risk assessment, no single tool includes all relevant risk factors, and, additionally, the true predictive validity of these tools are not clear.^1,5 Therefore, all risk assessment tools should be used in combination with a review of the individual’s medical history as well as good clinical judgment.

Braden Scale

The Braden Scale is the most widely used PI risk assessment tool because of its ease of use and its wider range of risk factors.^4,6 Multiple studies have found the Braden Scale to be highly specific, as well as sensitive.^7,8 The Braden Scale consists of the following 6 risk factor categories:

1. Sensory perception
2. Moisture
3. Activity
4. Mobility
5. Nutrition
6. Friction and shear

Each risk factor is scored from 1 to 4, except for friction and shear, which is scored from 1 to 3. Total scores can range from 6 to 23, with a higher score meaning a lower risk of developing PIs and vice versa. Individuals who score <18 are considered at risk of PI, and those who score <12 are considered at high risk of PI. In the case of the Braden Scale, a comprehensive risk assessment should also include factors that are not measured by the tool, such as:¹

• Skin status
• Diabetes
• Perfusion and oxygenation
• Increased body temperature
• Relevant blood work
• General health status

Norton Scale

The Norton Scale, which was originated in England during the 1960s, was the first pressure injury scale.⁹ It evaluates 5 items:⁵

1. Physical condition
2. Mental condition
3. Activity
4. Mobility
5. Incontinence

Waterlow Scale

The Waterlow Scale assesses the following 9 risk factors:⁵

1. Weight for height
2. Visual skin assessment
3. Sex and age
4. Incontinence
5. Mobility
6. Malnutrition Screening Tool score
7. Tissue malnutrition
8. Neurologic deficit
9. Major surgery or trauma

Cubbin-Jackson Scale

The Cubbin-Jackson Scale was specifically developed to assess PI risk in intensive care unit (ICU) patients and consists of both general and ICU patient-specific risk factors, such as:¹⁰

• Age
• Weight
• Past medical history
• General skin condition
• Mobility
• Nutrition
• Incontinence
• Hygiene
• Mental condition
• Hemodynamics
• Respiration
• Oxygen requirements

Prevention Strategies for Pressure Injury Development

Once individuals are confirmed to be at risk for PI development, prevention strategies that minimize modifiable risk factors should be implemented. Many interventions are available, including repositioning, use of support surfaces and offloading, nutritional support, and skin care and dressings.

Repositioning

Repositioning involves changing the position of lying or seated individuals at regular intervals to offload and redistribute pressure. The frequency of repositioning should consider the individual’s ability to reposition independently and their medical condition.

Support Surfaces

Support surfaces are designed to redistribute pressure and may include mattresses, chair cushions, and heel supports. The key characteristics to consider when selecting a support surface are the features that affect pressure redistribution, friction and shear force management, and microclimate. Heels may be offloaded with specialized boots or a support behind the legs to float the heels in the air. However, the support must distribute weight evenly along the calf and not place pressure on the Achilles tendon or popliteal vein.¹

Nutritional Screening

Another intervention, a validated nutritional screening, should be conducted in individuals at risk for PIs. Patients who are identified as malnourished should be referred to a registered dietitian nutritionist. The goals of nutritional support should be to optimize energy and protein intake and to encourage adequate fluid intake as appropriate.¹

Skin Care and Dressings

Although nutrition and hydration contribute to skin health, a focused skin care regimen can also be implemented and may include cleansing skin with nonalkaline soaps, moisturizing, proper drying of skin, cleaning skin promptly after incontinence episodes, and using barrier and high-absorbency incontinence products.

Conclusion

Performing a validated PI risk assessment and implementing individualized prevention strategies in at-risk patients can prevent PIs. Although the most widely used risk assessment tools include common risk factors, these scales do not incorporate all risk factors, especially given that epidemiologic research has increased in recent years. Thus, these tools must be used in combination with good clinical judgment.

References

1. Haesler E. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance; 2019.
2. Li Z, Lin F, Thalib L, et al. Global prevalence and incidence of pressure injuries in hospitalised adult patients: a systematic review and meta-analysis. Int J Nurs Stud. 2020;105:103546. doi:10.1016/j.ijnurstu.2020.103546
3. Munoz N, Litchford M, Cox J, et al. Malnutrition and pressure injury risk in vulnerable populations: application of the 2019 international clinical practice guideline. Adv Skin Wound Care. 2022;35(3):156-165. doi:10.1097/01.ASW.0000816332.60024.05
4. Huang C, Ma Y, Wang C, et al. Predictive validity of the Braden scale for pressure injury risk assessment in adults: a systematic review and meta-analysis. Nurs Open. 202;8(5):2194-2207. doi:10.1002/nop2.792
5. Chou R, Dana T, Bougatsos C, et al. Comparative Effectiveness Review No. 87. Pressure Ulcer Risk Assessment and Prevention: Comparative Effectiveness. Agency for Healthcare Research and Quality; 2013:12(13)-EHC148-EF. Accessed September 27, 2022. www.effectivehealthcare.ahrq.gov/reports/final.cfm
6. Adibelli S, Korkmaz F. Pressure injury risk assessment in intensive care units: comparison of the reliability and predictive validity of the Braden and Jackson/Cubbin scales. J Clin Nurs. 2019;28(23-24):4595-4605. doi:10.1111/jocn.15054
7. Park SH, Choi YK, Kang CB. Predictive validity of the Braden Scale for pressure ulcer risk in hospitalized patients. J Tissue Viability. 2015;24(3):102-113. doi:10.1016/j.jtv.2015.05.001
8. Jansen RCS, Silva KBA, Moura MES. Braden Scale in pressure ulcer risk assessment. Rev Bras Enferm. 2020;73(6):e20190413. doi:10.1590/0034-7167-2019-0413.
9. Norton D, McLaren R, Exton-Smith AN. An investigation of geriatric nursing problems in the hospital. J Gerontol. 1962;18(3): 290-291. doi:10.1093/geronj/18.3.290a
10. Jackson C. The revised Jackson/Cubbin pressure area risk calculator. Intensive Crit Care Nurs. 1999;15(3):169-175. doi:10.1016/s0964-3397(99)80048-2