A pressure injury assessment systematically evaluates a patient’s risk of developing pressure injuries and the status of any existing wounds. Accurate assessment guides prevention strategies, staging, treatment planning, and documentation to optimize patient outcomes.
Definitions
A pressure injury is a localized damage to the skin and underlying soft tissue, usually over a bony prominence as a result of unrelieved pressure.
Pressure injury assessment is a technique or process to identify the degree of injury as well as the risk for pressure injury so as to plan and implement the care effectively.
Stages of Pressure Injury
- Non blanchable erythema of intact skin.
- Partial-thickness skin loss with exposed dermis.
- Full-thickness skin loss.
- Full-thickness skin and tissue loss.
- Unstageable pressure injury: Obscured full-thickness skin and tissue loss.
Purposes
- To plan the care.
- To identify the risk factors and to take measures to reduce or eliminate them.
- To identify those at risk.
- To prevent the formation of pressure injury.
- To preserve microcirculation.
- To implement the nursing interventions that promote tissue tolerance to pressure and those that protect patients against external pressure, shear, and frictional forces.
Indications
Patients with the below-mentioned problems/who are elderly:
- Paralysis.
- Spinal cord injury.
- Reduced level of awareness.
- Unconsciousness.
- Malnourished.
- Heavily sedated.
- Problems with mobility including confinement to bed or wheel chair.
- Incontinence.
Preparation
Preparation of Equipment
- Assessment tools such as the Braden Scale, Norton Scale, and Waterlow scale.
- Pen and patient record for documentation.
Skin and Tissue Assessment
Perform a full skin inspection and palpation, focusing on bony prominences and areas under medical devices. Document the following in every assessment:
- Color changes (non-blanchable erythema, pallor)
- Temperature differences or persistent warmth
- Tissue consistency (induration, edema)
- Moisture, maceration, or dryness
- Presence of shear, friction, or device‐related damage
Inspect beneath dressings, braces, and tubing, and use good lighting or a pen‐light to detect early tissue damage.
The risk for pressure injury is assessed using the Braden Scale, Norton Scale, and Waterlow score.
- Braden Scale
The Braden Scale for predicting pressure ulcer risk is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstrom to assess the patient’s risk of developing a pressure ulcer and it consists of six components.
- Norton Scale
The Norton scoring system is the first pressure score risk evaluation scale to be created in 1962 at England. It is not widely used due to many contradictions.
| Norton Scoring System | ||
| Physical condition | Good | 4 |
| Fair | 3 | |
| Poor | 2 | |
| Very bad | 1 | |
| Mental condition | Alert | 4 |
| Apathetic | 3 | |
| Confused | 2 | |
| Stupor | 1 | |
| Activity | Ambulant | 4 |
| Walks with help | 3 | |
| Chair bound | 2 | |
| Bedfast | 1 | |
| Mobility | Full | 4 |
| Slightly impaired | 3 | |
| Very limited | 2 | |
| Immobile | 1 | |
| Incontinence | None | 4 |
| Occasional | 3 | |
| Usually urinary | 2 | |
| Urinary and fecal | 1 | |
Interpretation of Norton Scale
| Score | Interpretation |
| Greater than 18 | Low risk |
| Between 18 and 14 | Medium risk |
| Between 14 and 10 | High risk |
| Lesser than 10 | Very high |
Wound Measurement & Documentation
Accurate measurements and detailed records are essential for monitoring healing progression:
- Measure length, width, and depth using a sterile ruler or probe
- Note wound bed characteristics (percentage of granulation tissue, slough, eschar)
- Assess exudate amount, color, and odor
- Photograph wounds with date and measurement scale visible
Document all findings in the patient’s health record, including changes from previous assessments.
Assessment Frequency & Follow-Up
Reassess risk and existing wounds:
- On admission (within 6 hours) and at each shift change
- Whenever the patient’s condition or support devices change
- At least weekly for existing pressure injuries or more often if high risk
Use assessment results to update care plans, repositioning schedules, support surfaces, and nutritional or moisture management strategies.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
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