pressure ulcer risk scale

Introduction

Use of risk assessment tools may be associated with lower risk for development of pressure ulcers.

• persons with darker skin at risk of later detection of pressure injury
  • nonblanching erythema in darker-skinned populations may be difficult to detect

Commonly used scales

• Norton scale*
• Braden scale* (validated in non-white populations)

* most widely used tools to assess the risk of pressure injury development

* contrast with Bates-Jensen Wound Assessment Tool the best instrument for monitoring healing of pressure injuries

Frequency of risk assessment:

• more reliable if performed 24 hours after admission to health care setting (more reliable than upon admission)
• Critical/acute acure
  • on admission, then 48 hours later, then every day
• Medical/surgical
  • on admission, then 48 hours later, then every other day
• long-term care
  • on admission, then 48 hours later, then weekly for 4 weeks, then quarterly (or routinely, more frequently)
• home care
  • on admission, then 48 hours later, then weekly

More general terms

• numerical rating scale (NRS)

More specific terms

• Braden pressure ulcer risk scale
• Norton pressure ulcer risk scale
• Waterlow scale