1 Baran

Research Papers On Pressure Ulcers

1Mulago National Referral Hospital, Kampala, Uganda
2Department of Nursing, College of Health Sciences, Makerere University, Kampala, Uganda
3Johns Hopkins University School of Nursing, 525 N. Wolfe Street, Baltimore, MD 21205, USA

Copyright © 2014 Ivan Mwebaza et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Pressure ulcers have been identified as a major burden of hospitalization worldwide, and nurses are at the forefront of prevention. The purpose of this study was to determine the nurses’ knowledge and practices regarding risk factors, prevention, and management of pressure ulcers at a teaching hospital in Uganda. The study employed a descriptive cross-sectional design. Fifty-six Ugandan registered practicing nurses were sampled. A composite self-administered questionnaire and an observation checklist were utilized. The nurses had limited knowledge about critical parameters of pressure ulcers. Prevention practices were observed to be unreliable and uncoordinated related to a significant shortage of staff and logistics for pressure ulcer prevention. Nurses had poor access to current literature on pressure ulcer prevention. Translation of nurses’ knowledge into practice is possible if barriers like staff shortage, pressure relieving devices provision, and risk assessment tools are addressed at Mulago.

1. Introduction

Pressure ulcers remain the chief complications of prolonged hospitalization, specifically in situations of poor nutrition, increased moisture on the skin (e.g., incontinence), prolonged pressure, and compromised sensory stimuli [1, 2]. Pressure ulcers increase the cost of hospitalization, increase patient morbidity and mortality, and play a significant role in the spread of infection in the clinical area [3, 4]. Stage IV pressure ulcers have a high cost, and stopping the progression of early stage pressure ulcers can significantly reduce expenditures in resource strained facilities and decrease unnecessary pain impacting thousands of patient lives [3, 4].

The presence or absence of pressure ulcers has been generally regarded as a performance measure of quality nursing care and overall patient health [5]. On average, 60,000 people die each year worldwide due to pressure ulcer related causes [6]. The prevalence of pressure ulcers in European hospitals ranges from 1% to 11% in medical wards and 4.7% to 66% in surgical wards [7]. A study conducted in the United States demonstrated that pressure ulcers can be avoided by applying simple interventions like using risk factor assessment scales and regular turning of the patient by the nurses or by the nurse instructing a care taker [7].

In Uganda, little or no evidence is known about the capacity of nurses in regards to best practices with pressure ulcer care and prevention. Mulago Hospital remains the largest National Referral and Teaching hospital located in Kampala with a capacity of 1500 beds. The nurses form the largest number of health care employees (852) at Mulago Hospital. Nurses who work at this hospital are from various institutions of training with different educational levels (diploma and bachelor level), and all are registered with the Uganda Nurses Council. This study provides current evidence about Mulago Hospital nurses’ knowledge and practices as regard to risk factors, prevention, and management of pressure ulcers. In addition barriers to care of patients with pressure ulcers are identified.

2. Methods

2.1. Design

This was a descriptive cross-sectional quantitative study that employed nonprobability sampling technique. The study was approved by the internal review boards of the School of Health Sciences, Makerere University, and Mulago Hospital (REC REF 2012-022). Each of the participating nurses was required to sign a consent form before participating in the study.

2.2. Setting and Sample

The investigators recruited nurses who provided bedside care from three medical wards, three surgical wards, the burns ward, and the orthopedic ward of Mulago Hospital. This is the National Referral and Teaching Hospital with more than 400 bed capacity. These wards were identified as having the highest number of patients with pressure ulcers. A list of nurses working on the selected wards was obtained from the charge nurses and further crosschecked to exclude nurses on leave during the data collection period. All 84 nurses providing direct care on the day shift (8 am to 3 pm) in the selected wards were included in the sample.

2.3. Study Procedure

Nurses present on the selected wards were asked to complete a structured questionnaire after signing the consent form. No Internet access or reference materials were allowed on the ward to ensure that the nurses did not seek any external assistance to answer the questions. Of the 84 questionnaires distributed, 56 (66.6%) questionnaires were completed and included in the analysis.

A research assistant, utilizing a checklist, observed two to three nurses on each ward. The research assistant had not previously interacted with the nurses, and the nurses did not know when they would be observed. This helped minimize changes the staff might make in their usual routine care if they knew they were being observed. She noted the nurses’ actions, writing down their practices of prevention and management of pressure ulcers. The checklist noted the following: number of patients with at least a first degree pressure ulcer, number of times patients at risk or who had pressure ulcers were turned, availability of pressure reduction devices, treatment of skin areas at risk of developing pressure areas, moisture prevention, pressure ulcer debridement and dressing changes, consultation with colleagues in caring for patients at risk, and presence of a formal pressure ulcer assessment tool.

2.4. Study Instruments
2.4.1. Questionnaire

The self-administered questionnaire was written in English, and contained mainly closed ended questions. English, being the national language, is used in implementing education instructions as well as in professional communications in hospitals. The questionnaire was organized in the following four sections: sociodemographic characteristics, knowledge about pressure ulcers and risk factors, current practices to prevent and manage pressure ulcers, and barriers to providing best care.

2.4.2. Observational Checklist

The observational checklist included the following aspects: number of patients with at least a first degree pressure ulcer, frequency of turning patients at risks of pressure ulcers, availability of pressure ulcer reduction devices on the ward, continuous assessment and treatment of pressure areas by the nurses, moisture prevention, debridement and daily dressing of pressure ulcers, involvement of other care providers in the care for patients with pressure ulcers, and the presence of a formal assessment tool in assessing patients for the risk of pressure ulcers.

Before actual data collection, the study instruments were pretested with ten nurses in a private hospital in Kampala and adjusted accordingly. The questionnaire and the observational checklist took an average of 30 minutes each to complete.

2.5. Statistical Analysis

Data were analyzed using SPSS version 16 computer program. The participants’ demographic characteristics, level of knowledge, and practices regarding management and prevention of pressure ulcers were analyzed using descriptive statistics. Data were reported using means, percentages, and presented in tables.

3. Results

The majority (91.1%) of the participants were females. The age range was 21–60 years and less than half (44%) were between 21 and 30 years. The mean age was 25 years with a standard deviation of 2.4. Additionally participants were mostly diploma graduates (83.9%) with professional experience of 1–6+ years (Table 1).

Table 1: Demographic characteristics of study participants.

3.1. Nurses’ Knowledge about Pressure Ulcers

Nurses were considered to have average knowledge if at least five items for each section were identified correctly. Forty-four percent were able to identify at least five items. Less than half (39.3%) of the participants were aware that pressure ulcer management requires interdisciplinary collaboration. Less than half (42.9%) did not know that pressure ulcers develop in stages (Table 1). Half (50%) of the participants did not know that pressure ulcers could lead to permanent disabilities like bone destruction.

3.2. Risk Factors for Pressure Ulcers Development

Nurses were asked to identify possible risk factors for pressure ulcers (Table 2). More than half (59%) of the nurses were able to identify at least three risk factors for pressure ulcers. The majority (96.4%) identified immobility as a risk factor, and 92.9% identified pressure and friction while only 28.6% identified hypoxemia and anemia (10.7%). Less than half (42.9%) of the participants identified ischemia as a risk factor, while half (50%) identified neurologic diseases as a risk factor to pressure ulcers development.

Table 2: Nurses knowledge about pressure ulcers.

3.3. Strategies for Prevention and Management of Pressure Ulcers

Eight items were used to test the nurses’ knowledge and practices on the strategies of pressure ulcer prevention and management. All participants identified at least one strategy used to prevent and manage pressure ulcers (Table 2). Almost all nurses (98.2%) identified regular turning of patients as a preventive measure. An equal number of the participants identified proper hydration (42.9%) and a balanced diet (42.9%) of the patient as good practices for prevention and management of pressure ulcers.

Most of nurse participants (67.9%) saw at least one new patient with a pressure ulcer on their ward every month, and 32.1% confessed that they had not been observant of pressure ulcers while admitting patients on their ward. Only 28.6% of the nurses had turned patients they found at risk of pressure ulcers on a two-hourly basis. None of the nurses reported using any risk assessment tool for pressure ulcers assessment. When asked what they did on a daily basis when caring for patients with pressure ulcers, nurses responded that they were conducting patient education (96.4%), encouraging a balanced diet (58.9%), and using pressure reduction devices (33.9%) (Table 3).

Table 3: Nurses’ daily activities when caring for a patient at risk of developing pressure ulcers.

Analysis from checklist utilization demonstrated the nurse’s mode of care for patients who had or were at risk of developing pressure ulcers. The investigators recorded the parameter as being done if they observed at least two nurses completing the task on the study unit (Table 3). The nurses did not have any formal assessment tool on any ward. Pressure relieving devices were only in use on neurology. Some devices were also found on the medical wards but were not in use. The investigators found no nursing documentation of pressure ulcers management in patient records. However, nurses on medical and surgical wards were observed involving physicians and physiotherapists in the management of patients at risk of developing pressure ulcers.

3.4. Barriers to Providing Evidence Based Pressure Ulcer Preventive Practices

Potential and actual barriers to carrying out pressure ulcer prevention and management (Table 4). Inadequacies of supplies for pressure ulcer management and prevention and shortages of human resource for health, particularly nurses, were the most cited barriers to carrying out appropriate pressure ulcer management. Heavy workload related to shortage of staff (94.6%) and shortage of pressure relieving devices were also mentioned. Patients were also considered a barrier when they were identified as uncooperative (62.5%). Other barriers were poor access to pressure ulcer literature (37.5%) and inadequate coverage about pressure ulcers during training (23.2%) (Table 5).

Table 4: Observations made during the daily nursing activities (recorded for one week on each ward studied).

Table 5: Barriers to carrying out pressure ulcer management and prevention (multiple responses).

4. Discussion

The practicing nurses who participated in the study generally had inadequate knowledge about how pressure ulcers developed. They also did not have current knowledge on how to stage the pressure ulcers, nor did they know the prognosis of unpreventable and unmanaged pressure ulcers that often lead to permanent disability and bone destruction. They had inadequate understanding of the importance of interdisciplinary management. Similar findings were also reported in spinal cord injury units in the United States [8]. According to Louis (2007) knowing that pressure ulcers develop in stages was important in prediction, prevention, and their management to determine patient care outcomes.

Participants had some level of knowledge about risk factors although fewer knew about systemic risk factors such as hypoxemia, anemia, ischemia, and neurologic diseases. It is contended that pressure ulcer management is one of the nursing activities that require an interdisciplinary approach [9]. The interdisciplinary team involves in addition to a nurse, a patient educator, wound care physician, physiotherapist, and a dietician [8]. Pressure ulcer management and prevention also involves diet, physical exercise, wound care, and patient education. The nurse who is the main care provider should be knowledgeable and in position to mobilize the care team. Participants had inadequate knowledge about the need for a balanced diet among patients at risk. This was also true among nurses in Belgium [10]. Nutrition is even more important with the geriatric patients [3].

Teaching a patient about pressure ulcer prevention is paramount and is the best practice in patient management. Firstly it empowers the patient to follow instructions given by the care nurse and, secondly, it increases patient readiness to collaboration with the health care team. Additionally, keeping the skin and beddings of the patient dry is another important prevention intervention that nurses implemented and this is consistent with what Italian nurses consider as nursing activities [11]. This practice might not be directly targeting pressure ulcers alone, but also well documented that it is a good prevention measure [12, 13].

Only 12% of nurses in selected United States hospital turned their patients every two hours [14]. This was also reflected in the practice of the nurses in this study. In another study [10] substantive tissue damage on bony prominences took place during the first 3 to 4 hours of pressure, confirming the importance of turning patients regularly. In addition, in a study [15] performed on postsurgical patients, it was found that patients who were not turned developed first stage ulcers in just two hours. In resource limited settings like Uganda regular turning of the patient may be the only available means to reduce the incidence of pressure ulcers, a practice undertaken by the patients’ care taker under the supervision of the nurse.

One of the extrinsic risk factors for pressure ulcer development was pressure on bony prominences [16–20]. Prevention should be one of the health care teams’ priorities and in this study only a few nurses used pressure relieving devices on their wards. This is different from findings in a study in Belgium [17] where 69.2% of all patients at risk had pressure relieving devices. This study revealed that nurses were also not using a pressure ulcer risk assessment tool and were not even aware of the existence of such tools. This is significantly different from a study done in Ireland [16] where 95% of nurses were using the assessment tool, and 75% of the staff nurses could identify which tool was being used. In another study among Korean hospitals [21] 67% of staff nurses used pressure ulcer risk assessment tools. The importance of using a risk assessment tool in predicting pressure ulcers cannot be underemphasized [22]. In addition a good number of staff nurses had not consulted with any other health professional while taking care of patient at risk or with pressure ulcers. This may affect proper pressure ulcer care management of patients in the interdisciplinary approach; better outcome is expected [22, 23].

5. Implications for Nursing Practice

With noticeable increase in chronic diseases, trauma, and increasing number of aging population, nurses are required to be in position of providing pressure ulcer care and prevention. Their capacity to manage pressure ulcers needs to be enhanced through continuing education with support of the nursing administrators. Additionally, protocols to guide pressure ulcer care need to be developed and disseminated for use during care.

6. Recommendations for Future Research

There is need to carry out research based on the available risk assessment tools so as to identify individuals prone to pressure ulcers so that prevention and management is predictable. It would be imperative for the nurses to know, adopt, and implement evidence based risk assessment tools such as the Braden scale and also development or adoption of existing pressure ulcer protocols such that the nurses would not need to guess at the best strategies for pressure ulcer prevention and rapid healing.

7. Conclusions

The prevention and management of pressure ulcers is of great importance. However, nurses at Mulago Hospital have given it low priority stemming from inadequate knowledge and heavy workload such as one nurse having many patients to attend to. The nurse training schools and universities need to examine their curricula to address issues related to pressure ulcers prevention and treatment. Hospitals also need to devote more resources to prevent and manage pressure ulcers. Professionals should also meet their responsibility to provide continuous nursing education (CNE) and continuous medical education (CME) to staffs about pressure ulcers. Included and reflected in this education should be the importance of interdisciplinary collaboration.

Conflict of Interests

The authors have no conflict of interests.


The study was carried out in Mulago Hospital which is the National Referral and Teaching Hospital. The authors are also grateful to the nurses who participated in the study.

Once you have determined that you are ready for change, the Implementation Team and Unit-Based Teams should demonstrate a clear understanding of where they are headed in terms of implementing best practices. People involved in the quality improvement effort need to agree on what it is that they are trying to do. Consensus should be reached on the following questions:

In addressing these questions, this section provides a concise review of the practice, emphasizes why it is important, discusses challenges in implementation, and provides helpful hints for improving practice. Further information regarding the organization of care needed to implement these best practices is provided in Chapter 4 and additional clinical details are in Tools and Resources.

In describing best practices for pressure ulcer prevention, it is necessary to recognize at the outset that implementing these best practices at the bedside is an extremely complex task. Some of the factors that make pressure ulcer prevention so difficult include:

  • It is multidisciplinary: Nurses, physicians, dieticians, physical therapists, and patients and families are among those who need to be invested.
  • It is multidimensional: Many different discrete areas must be mastered.
  • It needs to be customized: Each patient is different, so care must address their unique needs.
  • It is also highly routinized: The same tasks need to be performed over and over, often many times in a single day without failure.
  • It is not perceived to be glamorous: The skin as an organ, and patient need for assessment and care, does not enjoy the high status and importance of other clinical areas.

3.1 What bundle of best practices do we use?

Given the complexity of pressure ulcer prevention, with many different items that need to be completed, thinking about how to implement best practices may be daunting. One approach that has been successfully used is thinking about a care bundle. A care bundle incorporates those best practices that if done in combination are likely to lead to better outcomes. It is a way of taking best practices and tying them together in a systematic way. These specific care practices are among the ones considered most important in achieving the desired outcomes.

The pressure ulcer bundle outlined in this section incorporates three critical components in preventing pressure ulcers:

  • Comprehensive skin assessment.
  • Standardized pressure ulcer risk assessment.
  • Care planning and implementation to address areas of risk.

Because these aspects of care are so important, we describe them in more detail in the subsequent subsections along with helpful clinical hints. While these three components of a bundle are extremely important, your bundle may stress other aspects of care. It should build on existing practices and may need to be tailored to your specific setting. Whatever bundle of recommended practices you select, you will need to take additional steps. We describe strategies to ensure their successful implementation as described in Chapter 4.

The challenge to improving care is how to get these key practices completed on a regular basis.


The bundle concept was developed by the Institute for Healthcare Improvement (IHI). Their Web site includes a more detailed description of what is a bundle: http://www.ihi.org/ihi/topics/criticalcare/intensivecare/improvementstories/whatisabundle.htm.

Additional Information

The following article describes successful efforts to improve pressure ulcer prevention that relied on the use of the components in the IHI bundle: Walsh NS, Blanck AW, Barrett KL. Pressure ulcer prevention in the acute care setting. J Wound Ostomy Continence Nurs 2009;36(4):385-8.

3.1.1 How are the different components of the bundle related?

Each component of the bundle is critical and to ensure improved care, each must be consistently well performed. To successfully implement the bundle, it is important to understand how the different components are related. A useful way to do this is by creating or following a clinical pathway. A clinical pathway is a structured multidisciplinary plan of care designed to support the implementation of clinical guidelines. It provides a guide for each step in the management of a patient and it reduces the possibility that busy clinicians will forget or overlook some important component of evidence-based preventive care.

Some of the advantages of these clinical pathways are to:

  • Reduce variation and standardize care.
  • Provide efficient, evidence-based care.
  • Improve outcomes.
  • Educate staff as to best practices.
  • Improve care planning.
  • Facilitate discussion among staff.


  • An example of a clinical pathway detailing the different components of the bundle is found in Tools and Resources (Tool 3A, Pressure Ulcer Prevention Pathway). This color-coded tool can be used by the hospital unit team in designing the new system, as a training tool for frontline staff, and as an ongoing clinical reference tool on the units. This tool can be modified, or a new one created, to meet the needs of your particular setting.
  • If you prepared a process map describing your current practices (described in section 2), you can compare that to desired practices outlined on the clinical pathway.

Practice Insights

Given the complexity of pressure ulcer preventive care, develop a clinical pathway that describes your bundle of best practices and how they are to be performed. 

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3.2 How should a comprehensive skin assessment be conducted?

The first step in our clinical pathway is the performance of a comprehensive skin assessment. Prevention should start with this seemingly easy task. However, as with most aspects of pressure ulcer prevention, the consistent correct performance of this task may prove quite difficult.

3.2.1 What is a comprehensive skin assessment?

Comprehensive skin assessment is a process by which the entire skin of every individual is examined for any abnormalities. It requires looking and touching the skin from head to toe, with a particular emphasis over bony prominences.

As the first step in pressure ulcer prevention, comprehensive skin assessment has a number of important goals and functions. These include:

  • Identify any pressure ulcers that may be present.
  • Assist in risk stratification; any patient with an existing pressure ulcer is at risk for additional ulcers.
  • Determine whether there are other lesions and skin-related factors predisposing to pressure ulcer development, such as excessively dry skin or moisture-associated skin damage (MASD).
  • Identify other important skin conditions.
  • Provide the data necessary for calculating pressure ulcer incidence and prevalence.

Additional Information

It is important to differentiate MASD from pressure ulcers. The following articles provide useful insights on how to do this:

  • DeFloor T, Schoonhoven L, Fletcher J, et al. Statement of the European Pressure Ulcer Advisory Panel: pressure ulcer classification. J Wound Ostomy Continence Nurs 2005;32:302-6.
  • Gray M, Bliss DZ, Doughty DB. Incontinence associated dermatitis a consensus. J Wound Ostomy Continence Nurs 2007;34(1):45-54.

3.2.2 How is a comprehensive skin assessment performed?

A comprehensive skin assessment has a number of discrete elements. Inspection and palpation, though, are key. To begin the process, the clinician needs to explain to the patient and family that they will be looking at their entire skin and to provide a private place to examine the patient's skin. Make sure that the clinicians' hands have been washed, both before and after the examination. Use gloves to help prevent the spread of resistant organisms.

Recognize that there is no consensus about the minimum for a comprehensive skin assessment. Usual practice includes assessing the following five parameters:

  • Temperature.
  • Color.
  • Moisture level.
  • Turgor.
  • Skin integrity (skin intact or presence of open areas, rashes, etc.).


Detailed instructions for assessing each of these areas are found in Tools and Resources (Tool 3B, Elements of a Comprehensive Skin Assessment).

Practice Insights

  • Take advantage of every patient encounter to evaluate part of the skin.
  • Always remind staff performing comprehensive skin assessments of the following helpful hints:
    • Don't forget to wash your hands before doing the skin assessment and after and to use gloves.
    • Make sure the patient is comfortable. Minimize exposure of body parts while you are doing the skin assessment.
    • Ask for assistance if needed to turn the patient in order to examine the patient's backside, with a particular focus on the sacrum.
    • Look at the skin underneath any devices such as oxygen tubing, indwelling urinary catheter, etc. Make sure to remove compression stockings to check the skin underneath them.

3.2.3 How frequently should comprehensive skin assessments be performed?

Comprehensive skin assessment is not a one-time event limited to admission. It needs to be repeated on a regular basis to determine whether any changes in skin condition have occurred. In most hospital settings, comprehensive skin assessment should be performed by a unit nurse on admission to the unit, daily, and on transfer or discharge. In some settings, though, it may be done as frequently as every shift. The admission assessment is particularly important on arrival to the emergency room, operating room, and recovery room. It may be appropriate to have more frequent assessments on units where pressure ulcers may develop rapidly, such as in a critical care unit; or less frequently on units in which patients are more mobile, such as psychiatry. Staff on each unit should know the frequency with which comprehensive skin assessments should be performed.

Optimally, the daily comprehensive skin assessment will be performed in a standardized manner by a single individual at a dedicated time. Alternatively, it may be possible to integrate comprehensive skin assessment into routine care. Nursing assistants can be taught to check the skin any time they are cleaning, bathing, or turning the patient. Different people may be assigned different areas of the skin to inspect during routine care. Someone then needs to be responsible for collecting information from these different people about the skin assessment. The risk with this alternative approach is that a systematic exam may not be performed; everybody assumes someone else is doing the skin assessment. Decide what approach works best on your units.

Action Steps

Assess whether your staff know the frequency with which comprehensive skin assessment should be performed.

3.2.4 How should results of the comprehensive skin exam be reported and documented?

In order to be most useful, the result of the comprehensive skin assessment must be documented in the patient's medical record and communicated among staff. Everyone must know that if any changes from normal skin characteristics are found, they should be reported. Nursing assistants need to be empowered and feel comfortable reporting any suspicious areas on the skin. Positive reinforcement will help when nursing assistants do find and report new abnormalities.

In addition to the medical record, consider keeping a separate unit log that summarizes the results of all comprehensive skin assessments. This sheet would list all patients present on the unit, whether they have a pressure ulcer, the number of pressure ulcers present, and the highest stage of the deepest ulcer. By regularly reviewing this sheet, you can easily determine whether each patient has had a comprehensive skin assessment. This log will also be critical in assessing your incidence and prevalence rates (go to section 5.1). Nursing managers should regularly review the unit log.

Action Steps

Assess the following:

  • Are results of the comprehensive skin assessment easily located for all patients?
  • Are staff comfortable reporting any observed skin abnormalities to physicians and nurse managers?


A sample sheet can be found in Tools and Resources (Tool 5A, Unit Log).

Practice Insights

  • Have a standardized place to record in the medical record the results of the skin assessment. A checklist or standardized computer screens with drop-down prompts with key descriptors of the five components of a minimal skin assessment can help capture the essential information obtained through the patient examination.
  • Communication among licensed and unlicensed members of the health care team is important in identifying and caring for any skin abnormalities. Some places have found it effective to use a diagram of a body outline that an unlicensed heath care worker can mark with any skin changes they might see while bathing or performing care activities.

3.2.5 What are some barriers to practice?

There are many challenges to the performance of comprehensive skin assessments. Be especially concerned about the following issues:

  • Finding the time for an adequate skin assessment: As much as possible, integrate the comprehensive skin examination into the normal workflow. But remember that this is a separate process that requires a specific focus by staff if it is to be done correctly.
  • Determining the correct etiology of wounds: Many different types of lesions may occur on the skin and over bony prominences. In particular, do not confuse moisture-associated skin changes with pressure ulceration. If unsure about the etiology of a lesion, ask someone else who may be more knowledgeable.
  • Using documentation forms that are not consistent with components of skin assessments: Develop forms that will facilitate the recording of skin assessments.
  • Having staff who do not feel empowered to report abnormal skin findings: Communication among nursing assistants, nurses, and managers is critical to success. If communication problems exist, staff development activities targeting cross-level communication skills may be in order. Nurses and managers may need to solicit and positively reinforce such reporting if nursing assistants do not have confidence in this area. Develop methods to facilitate communication. One example would be a sticky note pad that includes a body outline, patient name, and date. Aides would mark down any suspicious lesions and give the note to nurses.


An example of a notepad to be used for communication among nursing assistants, nurses, and managers can be found in Tools and Resources (Tool 3C, Pressure Ulcer Identification Notepad).

3.2.6 How can practice be improved?

Comprehensive skin assessment requires considerable skill and ongoing efforts are needed to enhance skin assessment skills. Take advantage of available resources to improve skills of all staff. Encourage staff to:

  • Ask a colleague to confirm their skin assessments. Having a colleague evaluate the skin assessment will provide feedback as to how they are doing and will help correct documentation errors.
  • Perform skin assessments with an expert. Consider having an expert or nurse from another unit round with unit staff quarterly to confirm findings from the comprehensive skin assessment.
  • Ask for clarification when they are unsure of a lesion. Take advantage of the local wound care team or other staff who may be more knowledgeable.
  • Use available resources to practice their ability to differentiate the etiology of skin and wound problems.


This slide show illustrates how to perform a skin assessment: www.authorstream.com/Presentation/ann5844-150720-skin-assessment-nursing...

Watch these free videos developed by the Minnesota Hospital Association on how to perform a skin assessment:

Consult the European Pressure Ulcer Advisory Panel Web site (http://www.epuap.org) for useful advice on evaluating erythema and the proper staging of pressure ulcers. Take the staging self-assessment examination to see how much you really know. Information on differentiating pressure ulcers from other skin problems is available at: http://www.puclas.ugent.be/puclas/e/.

Practice Insights

A full-body skin inspection does not have to mean visualizing all aspects of the patient in the same time period.

  • When applying oxygen, check the ears for pressure areas from the tubing.
  • If the patient is on bed rest, look at the back of the head during repositioning.
  • When auscultating lung sounds or turning the patient, inspect the shoulders, back, and sacral/coccyx region.
  • When checking bowel sounds, look into skin folds.
  • When positioning pillows under calves, check the heels and feet (using a hand-held mirror makes this easier).
  • When checking IV sites, check the arms and elbows.
  • Examine the skin under equipment with routine removal (e.g., TENS units, restraints, splints, oxygen tubing, endotracheal tubes).
  • Each time you lift a patient or provide care, look at the exposed skin, especially on bony prominences.
  • Pay special attention to areas where the patient lacks sensation to feel pain or has had a breakdown in the past and if epidural/spinal pain medications are being administered. 

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3.3 How should a standardized pressure ulcer risk assessment be conducted?

As discussed above, one purpose of comprehensive skin assessment is to identify visible changes in the skin that indicate increased risk for pressure ulcer development. However, factors other than skin changes must be assessed to identify patients at risk for pressure ulcers. This can best be accomplished through a standardized pressure ulcer risk assessment.

3.3.1 What is a standardized pressure ulcer risk assessment?

After a comprehensive skin examination, pressure ulcer risk assessment is the next step in pressure ulcer prevention. Pressure ulcer risk assessment is a standardized and ongoing process with the goal of identifying patients at risk for the development of a pressure ulcer so that plans for targeted preventive care to address the identified risk can be implemented. This process is multifaceted and includes many components, one of which is a validated risk assessment tool or scale.

Other risk factors not quantified in the assessment tools must be considered. Risk assessment does not identify who will develop a pressure ulcer. Instead, it determines which patients are more likely to develop a pressure ulcer, particularly if no special preventive interventions are introduced. In addition, risk assessment may be used to identify different levels of risk. More intensive interventions may be directed to patients at greater risk.

Action Steps

Ask yourself and your team:

  • Do you have a policy about who is responsible for the risk assessment on admission and thereafter?
  • Does everyone know the process for performing risk assessment?

3.3.2 Why is a pressure ulcer risk assessment necessary?

Pressure ulcer risk assessment is essential for a number of reasons:

  • It aids in clinical decisionmaking. Many clinicians are not skilled in identifying patients at risk for developing pressure ulcers. Use of a standardized risk assessment helps to direct the process by which clinicians identify those at risk and quantify the level of this risk.
  • It allows the selective targeting of preventive interventions. Pressure ulcer prevention is resource intensive. Resources should be targeted toward those at greatest risk who would most-benefit.
  • It facilitates care planning. Care plans focus on the specific dimensions that place the patient at greatest risk.
  • It facilitates communication between health care workers and care settings. Workers have a common language by which they describe risk.

Action Steps

Ask yourself and your team:

  • Do the unit staff understand why they are doing the risk assessment?
  • Are unit staff communicating the risk assessment results to all clinicians who need to know?

3.3.3 How is risk assessment performed?

Pressure ulcer risk assessment is a standardized process that uses previously developed risk assessment tools or scales, as well as the assessment of other risk factors that are not captured in these scales. Risk assessment tools are instruments that have been developed and validated to identify people at risk for pressure ulcers. Typically, risk assessment tools evaluate several different dimensions of risk, including mobility, nutrition, and moisture, and assigns points depending on the extent of any impairment.

Clinicians often believe that completing the risk assessment tool is all they need to do. Help staff understand that risk assessment tools are only one small piece of the risk assessment process. The risk assessment tools are not meant to replace clinical assessments and judgment but are to be used in conjunction with clinical assessments.

Many other factors might be considered as part of clinical judgment. However, many of these factors, such as having had a stroke, are captured by existing tools through the resulting immobility. Several additional specific factors should be considered as part of the risk assessment process. However, also remember that patients who are just "not doing well" always seem to be at high risk for pressure ulcers.

  • Presence of a pressure ulcer: All patients with an existing pressure ulcer should be considered at-risk for an additional ulcer.
  • Prior Stage III or IV pressure ulcers: When Stage III or IV ulcers close through a process of scar tissue formation and eventual epithelialization, the resulting skin is not normal as it lacks its former tensile strength and is very prone to break down again.
  • Hypoperfusion states: Patients who are not perfusing vital organs as a result of conditions such as sepsis, dehydration, or heart failure are also not adequately perfusing the skin. Minimal amounts of pressure may then cause ulceration.
  • Peripheral vascular disease: Because of the limited blood supply to the legs, these patients are predisposed to pressure ulcers of the feet, particularly the heels.
  • Diabetes: Patients with diabetes have consistently been shown to be at increased risk of pressure ulcers.
  • Smoking: Smoking interferes with oxygen delivery. Smoking is associated with recurrence of pressure ulcers postsurgery and likely increases risk of new pressure ulcers.
  • Restraint use: Patients with physical restraints have limited mobility in addition to having pressure applied at the site of the restraints. Chemical restraints with resulting sedation may lead to rapid decline in mobility.
  • Spinal cord injury: Immobility, incontinence, and impaired sensation may combine to place these patients at exceptionally high risk. The level and completeness of the spinal cord injury is critical in this determination. Also consider if the individual is receiving epidural/spinal pain medication.
  • End-of-life/palliative care: Individuals in the terminal stages of disease may have failure of multiple organ systems, including the skin.
  • Operating room (OR) and emergency room (ER) stays: Prolonged time on a hard surface or in one position increases the risk of skin breakdown. This often happens in an OR or ER, with lengthy procedures, or while transporting a patient,. Always consider the length of time that the patient may need to stay in one position. Patients who undergo a procedure longer than 4 hours are at particularly high risk.

Practice Insights

Comprehensive risk assessment includes both the use of a standardized scale and an assessment of other factors that may increase risk of pressure ulcer development.

3.3.4 What risk assessment scales are used most often?

Remember that risk assessment scales are only one part of a pressure ulcer risk assessment. These scales or tools serve as a standardized way to review some factors that may put a person at risk for developing a pressure ulcer. Research has suggested that these tools are especially helpful in identifying people at mild to moderate risk as nurses can identify people at high risk or no risk. All risk assessment scales are meant to be used in conjunction with a review of a person's other risk factors and good clinical judgment.

While some institutions have created their own tools, two risk assessment scales are widely used in the general adult population: the Norton Scale and the Braden Scale. Both the Norton and Braden scales have established reliability and validity. When used correctly, they provide valuable data to help plan care.

The Norton Scale is made up of five subscales (physical condition, mental condition, activity, mobility, incontinence) scored from 1-4 (1 for low level of functioning and 4 for highest level of functioning). The subscales are added together for a total score that ranges from 5 to 20. A lower Norton Scale score indicates higher levels of risk for pressure ulcer development. Scores of 14 or less generally indicate at-risk status.

The Braden Scale is made up of six subscales (sensory perception, moisture, activity, mobility, nutrition, friction/shear) scored from 1 to 4 or 1 to 3 (1 for low level of functioning and 4 for the highest level or no impairment). Total scores range from 6 to 23. A lower Braden Scale score indicates higher levels of risk for pressure ulcer development. Scores of 18 or less generally indicate at-risk status. This threshold may need to be adjusted for the specific patient population on your unit or according to your hospital guidelines.

Other scales may be used instead of the Norton or Braden scales. What is critical is not which scale is used but just that some validated scale is used in conjunction with a consideration of other risk factors not captured by the risk assessment tool. By validated, we mean that they have been shown in research studies to identify patients at increased risk for pressure ulcer development.

Action Steps

Ask yourself and your team:

  • Are we using a risk assessment tool in conjunction with the assessment of additional specific patient risk factors?
  • When and what kind of training did the staff receive on how to use and interpret the scales?
  • Are risk assessment results being used as a basis for planning care?


Copies of the Braden and Norton scales are included in Tools and Resources (Tool 3D, Braden Scale , and Tool 3E, Norton Scale ).


Additional information on the Braden and Norton scales may be found at the following Web sites:

3.3.5 What risk assessment should be used in special populations?

The risk assessment tools described above are appropriate for the general adult population. However, these tools may not work as well in terms of differentiating the level of risk in special populations. These include pediatric patients, patients with spinal cord injury, palliative care patients, and patients in the OR. Risk assessment tools exist for these special settings but they may not have been as extensively validated as the Norton and Braden scales.


Consider the following resources for risk assessment in special populations:

  • Palliative Care: Hunters Hill Marie Curie Centre Risk Assessment Tool. Chaplin J, McGill M. Pressure sore prevention. Palliative Care Today 1999;8(3):38-39.
  • Home Care: Braden Scale for Predicting Pressure Sore Risk in Home Care. Available at: www.bradenscale.com.
  • Pediatrics:
    • Braden Q (21 days to 8 years). Quigley SM, Curly MAQ. Skin integrity in the pediatric population: preventing and managing pressure ulcers. J Spec Pediatr Nurs 1996;1(1):7-18.
    • Glamorgan Scale (birth to 18 years). Willock J, Harris C, Harrison J, et al. Identifying the characteristics of children with pressure ulcers. Nursing Times 2005;101(11):40-43.
    • Pediatric Waterlow (neonate to 16 years). Waterlow J. Pressure sore risk assessment in children. Pediatr Nurs 1997;9(6):21-24.
    • Neonatal Skin Risk Assessment Scale (NSARS) (26 to 46 weeks). Huffines B, Logsdon MC. The neonatal skin risk assessment scale for predicting skin breakdown in neonates. Issues Compr Pediatr Nurs 1997;20:103-14.

3.3.6 What information do you get from using a risk assessment scale?

Overall scale scores provide data on general pressure ulcer risk and help clinicians plan care according to the amount of risk (high, moderate, low, etc). Subscale scores provide information on specific deficits such as moisture, activity, and mobility. These deficits should be specifically addressed in care plans. Remember, even a score that indicates no risk does not guarantee that a person will not develop a pressure ulcer, especially as their condition changes.

3.3.7 How often is a pressure ulcer risk assessment done?

Consider performing a risk assessment in general acute care settings on admission and then daily or with a significant change in condition. However, pressure ulcer risk may change rapidly, especially in acute care settings. Therefore, recommendations for frequency of risk assessment will vary.

In settings where patients' status may change quickly, such as in critical care, risk assessment should be performed more frequently, such as every shift. In the OR, recommendations exist to assess on admission, at discharge to the recovery room, and periodically for operations lasting longer than 4 hours. (Consider the time in the holding and recovery rooms when assessing the time). For patients with more stable conditions, such as acute rehabilitation, pressure ulcer risk assessment may be less frequent. What is important is that the frequency of pressure ulcer risk assessment be individualized to the person's unique setting and circumstances.

Action Steps

Considering the specific patient situation, ask yourself and your team:

  • How often should the risk reassessment be done on your unit?
  • How often is it actually being done?


For more information on risk assessment in the OR, see the recommendations from the Minnesota Hospital Association Safe Skin Campaign: http://www.mnhospitals.org/inc/data/tools/SafeSkin-Toolkit/OR-pressure-ulcer-recommendations.pdf.

3.3.8 How should pressure ulcer risk assessment be documented and communicated?

Documenting pressure ulcer risk is essential to ensure that all staff are aware of patients' pressure ulcer risk status. While documenting in the medical record is necessary, documentation alone may not be sufficient to ensure that all staff know the level of risk. Among the options to consider for complete documentation are:

  • Having a dedicated form (computerized or paper) in the medical record.
  • Incorporating results in the daily patient flowsheets.
  • Including results as part of patient report or handover.
  • Having a separate form for the pressure ulcer risk assessment tool that allows multiple date entries.
  • Putting results on patient card or daily patient care worksheet.

Remember that in documenting pressure ulcer risk, you want to incorporate not only the score and subscale scores of the standardized risk assessment tool, but also other factors placing the individual at risk. This information is often included in narrative text.

Risk status should be communicated orally at shift change or by review of the written material in the medical record or patient care worksheet. Consider innovative approaches to conveying level of risk. For example, some facilities have color-coded the patient wristband, placed stickers on the patient chart or worksheet, or used picture magnets on the doors to indicate risk status.

3.3.9 How can we improve the accuracy of pressure ulcer risk assessment?

The accuracy of a risk assessment scale depends on the person completing it. Experience has shown tremendous variability among staff even when evaluating the same patient. Therefore, training in how to use the scale is needed to ensure consistency.

Action Steps

It is important to check how risk assessment is being performed on each unit.

  • Look at the patient record and see if the scores have been consistent. Wide fluctuations in risk are unusual in stable patients. Similarly, when there is a major change in clinical condition, has the risk score changed?
  • Select a patient and see if the assessment is accurate. Staff may give the patient "the benefit of the doubt" and make scores better than they are.


Information may be found in the Hartford Institute for Geriatric Nursing's Try This Series at http://www.consultgerirn.org/uploads/File/trythis/issue05.pdf.  Refer to Issue 5 under the General Assessment Series.

Lindgren M, Unosson M, Krantz AM, et al. A risk assessment scale for the prediction of pressure sore development: reliability and validity. J Adv Nurs 2002;38(2):190-9.

Additional Information

Learn more about risk assessment:

  • Magan MA, Maklebust J. The nursing process and pressure ulcer prevention: making the connection. Adv Skin Wound Care 2009;22(2):83-92.
  • Magan MA, Maklebust J. Multisite Web-based training in using the Braden Scale to predict pressure sore risk. Adv Skin Wound Care 2008;21(3):124-33.

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