Pressure ulcers, commonly known as bed sores, are localized injuries to the skin and the underlying tissue, typically forming over bony prominences. These injuries occur due to sustained pressure that restricts blood flow, leading to tissue damage and eventual cell death. They represent a significant safety concern across all healthcare environments. The primary goal of a pressure ulcer risk assessment is to proactively identify individuals susceptible to developing these injuries so that preventive measures can be immediately put into place.
Initial Assessment Frequency
A structured risk assessment must be completed immediately upon a patient’s admission or intake to any healthcare setting, such as a hospital or long-term care facility. This urgency is based on the evidence that a large percentage of pressure ulcers develop soon after a patient enters a facility, often within the first two weeks. Clinical guidelines recommend that this initial assessment occur as soon as possible, often specifying a timeframe of within eight hours of admission.
The rationale for this immediate action is to establish a patient’s baseline risk profile before any potential deterioration occurs. Delaying the assessment means delaying the implementation of prevention strategies.
Ongoing Monitoring and Reassessment Triggers
Beyond the initial intake, the frequency of reassessment is determined by the patient’s care environment and any changes in their clinical status, meaning the monitoring is both scheduled and event-based. In high-acuity settings, such as an Intensive Care Unit (ICU), a patient’s condition can change rapidly, necessitating a reassessment as frequently as every shift, or at least daily. For patients in long-term care, the standard schedule is typically less frequent, often weekly for the first four weeks, and then quarterly if the patient’s condition remains stable.
A patient’s physical state can shift quickly, requiring an immediate, unscheduled reassessment regardless of the established routine. Event-based triggers include a transfer to a new unit or after any major surgical or interventional procedure. Significant physical changes, such as a sudden deterioration in mobility, a major change in nutritional status, or the onset of fever or sepsis, also require an immediate update to the risk assessment.
Tools Used for Risk Assessment
Healthcare providers utilize validated assessment scales to quantify a patient’s risk and guide preventive actions. The Braden Scale for Predicting Pressure Sore Risk is one of the most widely used tools, evaluating six specific subscales:
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction/shear
Each category is assigned a numerical score, typically ranging from one to four, which are then totaled to give an overall risk score. A lower total score indicates a greater risk of developing a pressure injury; for instance, a score of 18 or less generally places an adult patient into an at-risk category.
The Norton Scale is another established tool, typically used for adult patients, which assesses five categories: physical condition, mental condition, activity, mobility, and incontinence. Similar to the Braden Scale, each factor is scored, and the resulting total score, which ranges from five to twenty, correlates to the patient’s risk level. A score of 14 or below on the Norton Scale usually indicates a heightened risk for pressure ulcer development. These tools provide a structured, objective method to identify risk factors and allow clinicians to tailor specific interventions to the patient’s individual needs.