Pressure Ulcer Risk Assessment and Prevention
What is the Pressure Ulcer Index
The term "Pressure Ulcer Index" is not a standardized clinical tool; instead, clinicians use validated risk assessment scales—primarily the Braden Scale—to identify patients at risk for developing pressure ulcers. 1
The Braden Scale evaluates 6 parameters:
Each parameter is scored, with a total score ≤18 indicating high risk for pressure ulcer development. 2, 3 Lower scores indicate progressively higher risk, though the scale has limited diagnostic accuracy with sensitivity of approximately 57% and specificity of 68%. 4
Alternative Risk Assessment Tools
Other validated scales include:
- Norton Scale: Evaluates 5 parameters (physical condition, mental state, activity, mobility, incontinence) with scores ranging 5-20 points, where lower scores indicate higher risk. 1
- Waterlow Scale: Shows similar diagnostic accuracy to Braden. 5
- Cubbin and Jackson Scale: Specifically developed for ICU patients but shows no superior accuracy. 6
The American College of Physicians recommends the Braden Scale as the primary tool due to its better balance between sensitivity and specificity, though all scales have low diagnostic accuracy and should not replace clinical judgment. 1, 4
Critical Limitation of Risk Assessment Scales
Risk assessment tools do not reduce pressure ulcer incidence compared to experienced clinical judgment alone—their value lies in structuring preventive interventions, not as therapeutic measures themselves. 4 Low-quality evidence shows that the Waterlow and Ramstadius scales were equivalent to clinical judgment for reducing pressure ulcer incidence. 5
Important Pitfall to Avoid
Approximately 19% of patient-days classified as "not-at-risk" (Braden score >18) still exhibit low subscale scores warranting targeted interventions. 4, 3 Relying solely on the total score can miss at-risk patients—clinicians must assess individual subscale domains to identify specific vulnerabilities. 4, 3
Preventive Interventions for High-Risk Patients
1. Support Surface Selection (Highest Priority)
Use advanced static mattresses or advanced static overlays immediately for all patients at increased risk—this is the only intervention with moderate-quality evidence showing reduced pressure ulcer incidence compared to standard hospital mattresses. 5, 6
Do not use alternating-air mattresses or overlays, as they show no clear benefit over static surfaces, cost significantly more, and add logistical burden without improving outcomes. 4, 6
2. Systematic Repositioning Protocol
Implement repositioning every 2-4 hours around the clock for all at-risk patients, with pressure zone checks at each turn. 4, 6 The standard is every 2 hours for hemodynamically stable patients, though individual tolerance should guide adjustments within this window. 4
Use the 30-degree tilt position rather than standard 90-degree lateral rotation, which reduces pressure on bony prominences (relative risk 0.62,95% CI 0.10-3.97). 4, 6 Avoid the flat supine position entirely as it concentrates pressure on vulnerable areas. 4
When using advanced pressure-reducing mattresses, repositioning intervals can be extended to 4 hours without increased ulcer incidence. 4
3. Daily Skin Assessment
Conduct thorough visual and tactile skin checks of all at-risk areas at least once daily, with particular attention to the sacrum, heels, ischium, and occiput. 4 Document each position change with time and skin assessment findings to ensure adherence. 4
4. Moisture Management and Skin Care
Keep skin clean and dry at all times, addressing urinary or fecal incontinence promptly, as moisture increases skin maceration and ulcer risk. 4, 6 Use skin cleansers other than soap, which showed decreased pressure ulcer risk in low-quality evidence. 6
Apply barrier sprays and lubricants judiciously to protect skin from friction during repositioning. 4
5. Heel Protection
Elevate heels off the bed surface using specialized devices or pillows to avoid interosseous contact, particularly at the knees. 4, 6 Place multilayer foam dressings over the sacrum and heels as an additional preventive strategy for high-risk patients. 6
6. Nutritional Support
Provide high-protein oral nutritional supplementation for patients at risk, as this reduces pressure ulcer development (odds ratio 0.75,95% CI 0.62-0.89). 6 Protein or amino acid supplementation also reduces wound size in patients who develop ulcers despite prevention efforts. 6
7. Early Mobilization
Begin mobilization as soon as the patient is medically stable, starting with passive range-of-motion exercises for at least 20 minutes per zone, even in patients who cannot actively participate. 4 Progress to active mobilization using a structured protocol aiming for the highest achievable mobility level at each session. 4
Multicomponent Implementation Strategy
Establish a bundled prevention program that includes:
- Simplification and standardization of pressure ulcer interventions and documentation 5, 4
- Multidisciplinary team involvement with designated leadership 5, 4
- Designated "skin champions" to educate personnel 5, 4
- Ongoing staff education 5, 4
- Sustained audit and feedback with regular all-facility meetings 5, 4
This bundled approach has demonstrated cost savings of approximately $11.5 million annually in hospital systems while significantly reducing pressure ulcer prevalence. 5, 4
Key Risk Factors to Identify
Risk factors include:
- Older age 5, 4
- Black race or Hispanic ethnicity 5, 4
- Lower body weight (reduces natural cushioning over bony prominences) 5, 4
- Cognitive impairment (limits ability to communicate discomfort or change position) 5, 4
- Physical impairments preventing autonomous mobility 5, 4
- Urinary or fecal incontinence 5, 4
- Comorbidities affecting tissue integrity: diabetes, edema, impaired microcirculation, hypoalbuminemia, malnutrition 5, 4
Special Considerations
Do not delay preventive interventions while waiting for formal risk assessment—clinical judgment identifying obvious risk factors should prompt immediate action. 4 The use of vasopressors or catecholamines is not a contraindication to position changes in hemodynamically stable patients. 4
For patients with increased intracranial pressure, position the head in a centered position and avoid lateral rotation during any necessary repositioning. 4