RISK ASSESSMENT TOOLS
Reducing pressure ulcers/injury through risk assessment
Prevention of pressure damage depends on the identification and reduction of risk factors. All patients should have a pressure ulcer/injury risk assessment undertaken as soon as possible. For the UK, the recommendation is within six hours of admission into an acute area (NICE, 2014).
Many healthcare settings use risk assessment tools. These include:
- Waterlow Scale (1985)
- Norton Risk Assessment Scale
- Braden Scale
- PPURA (Preliminary Pressure Ulcer Risk Assessment)
- PURPOSE-T
(NATVNS, 2014; Stephenson, 2017)
These tools have been criticised for their lack of validity and reliability. However, as stated above, their use as an aide-memoir is encouraged (EPUAP, 2019).
This module will now look at two of the most widely used pressure ulcer/injury assessment tools, devised by Judy Waterlow in 1985 and Barbara Braden and Nancy Bergstrom in 1987.
The Braden Score
The Braden Scale for Predicting Pressure Ulcer Risk is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstorm (Kozier et al., 2008). The Braden Scale assesses a patient’s risk of developing a pressure ulcer/injury by examining six criteria:
- Sensory Perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and Shear
(Cassell, 2011)
To access more information on the Braden Scale, please see link below: http://www.bradenscale.com/images/bradenscale.pdf
The Waterlow Score
The Waterlow assessment scale was introduced into practice in 1985 (Waterlow, 1985) and updated with the publication of “The Waterlow Pressure Ulcer Prevention Manual” (revised 2005), which is a comprehensive guide providing detailed background information on the Waterlow Scale and how to use it effectively.
The Waterlow Pressure Ulcer Prevention/Treatment Policy (Waterlow, 2005) uses the factors that contribute to pressure ulcer/injury development to provide a ‘Waterlow score’ for a patient. This score is then used to determine the best course of action to prevent ulcer/injury development and/or to aid ulcer healing.
Adapted Waterlow Pressure Area Risk Assessment Chart
Undertake and document risk assessment within six hours of admission or on first home visit. Reassess if there is a change in the individual’s condition and repeat regularly according to local protocol.
| Score | ||
|---|---|---|
| Sex | Male | 1 |
| Female | 2 | Age | 14-49 | 1 |
| 50-64 | 2 | |
| 65-74 | 3 | |
| 75-80 | 4 | |
| 81+ | 5 | |
| Continence | Complete/catheterised | 0 |
| Incontinent urine | 1 | |
| Incontinent faeces | 2 | |
| Doubly incontinent (urine & faeces) | 3 | |
| Skin Type – Visual Risks Area | Healthy | 0 |
| Tissue paper (thin/fragile) | 1 | |
| Dry (appears flaky) | 1 | |
| Oedematous (puffy) | 1 | |
| Clammy (moist to touch)/pyrexia | 1 | |
| Discoloured (bruising/mottled) | 2 | |
| Broken (established ulcer) | 3 | |
| Mobility | Fully mobile | 0 |
| Restless/fidgety | 1 | |
| Apathetic (sedated/depressed/reluctant to move) | 2 | |
| Restricted (restricted by severe pain or disease) | 3 | |
| Bedbound (unconscious/unable to change position/traction) | 4 | |
| Chair bound (unable to leave chair without assistance) | 5 | |
| Nutritional Element | Unplanned weight loss in past 3-6 months | |
| <5% | 0 | |
| 5-10% | 1 | |
| 10% | 2 | |
| BMI >20 | 0 | |
| BMI 18.5-20 | 1 | |
| BMI < 18.5 | 2 | |
| Patient/client acutely ill or no nutritional intake > 5 days | 2 | |
| Special Risks – Neurological Deficit | Diabetes/ MS/ CVA/ motor/ sensory/ paraplegia Max 6 | 6 |
| Special Risks – Medication | Cytotoxic, anti-inflammatory, long term/high dose steroid Max 4 | 4 |
| Special Risks – Surgery/Trauma | On table > 6 hours | 8 |
| Orthopaedic/ below waist/spinal (up to 48 hours post op) | 5 | |
| On table > 2 hours (up to 48 hours post op) | 5 | |
More than one score can be used in some categories
10+= ‘At Risk’: 15+ = ‘High Risk’: 20+ = ‘Very High Risk’Copyright Waterlow, 1985. Revised 2005*
* The 2005 revision incorporates the research undertaken by Queensland Health.
The use of risk assessment tools, e.g. Waterlow or Braden score, are used to identify the patient’s risk of pressure ulcer/injury development. The risk assessment scales will not identify that a patient will develop a pressure ulcer/injury; it will only identify patients who are likely to be at risk based upon a combination of existing risk factors.
When planning care for patients, pressure ulcer prevention should focus on the prevailing risk and address the underlying pathophysiology, including managing pressure, skin integrity and nutrition.
The risk level will change throughout the duration of the patient’s care. Therefore, risk assessments should be carried out on a regular basis and any time there is a change in the patient’s condition. It is also important to clearly document the assessment to ensure the risk factors are addressed and the appropriate preventive measures are implemented, evaluated, and subsequently documented in the patient’s plan of care.
PURPOSE T
PURPOSE T is a relatively new tool that has been developed and is currently being utilised within the UK.
PURPOSE-TAll risk assessment tools are based on factors known to predispose an individual to pressure ulcer/injury development.
All of the risk assessment tools have been researched and validated. The score achieved through the risk assessment determines the appropriate management of the patient.
The score would then be considered when choosing a support surface, e.g. a patient with a very high risk, with or without pressure ulcers/injuries, would warrant an alternating pressure mattress. Risk assessment tools should also be used in conjunction with clinical judgment, not as a replacement. (Callum, 2001; Norton et al., 2018; EUPAP, 2019)