Pressure injury prevention risk assessment

Clinical question: What is the most reliable method of pressure injury risk assessment for the intensive care patient?

SectionRecommendationGrade of recommendation
2. Use a pressure injury risk assessment scale in conjunction with a comprehensive visual assessment to determine the patient’s risk of pressure injury and to inform the development of a prevention plan. Consensus
3. The Braden scale is the recommended validated and reliable tool for assessing pressure injury risk in critically ill adults. (30, 31) B

Inspect all of the skin and devices attached to the patient within two hours of admission, at each repositioning and each shift change to identify indications of pressure injury including:

  • for fair skin races – erythema and for darker pigmented skin – persistent blue or purple hue
  • blanching response
  • localised heat
  • oedema
  • induration
  • skin breakdown. ( 2)

The skin and mucosa impacted by invasive medical devices (including but not limited to nasogastric tubes, tracheal tubes, urinary catheter, faecal management devices, nasopharyngeal airway and intravascular devices) should be inspected:

  • at the beginning of the shift
  • each time the patient is repositioned or adjusted
  • where applicable when dressings are changed.
6. Documentation of pressure injury risk assessment scale and visual inspection should occur at a minimum of once each shift. Consensus

All patients are to be regularly assessed for pain, especially in relation to repositioning and in the presence of pressure injuries. If the patient has a pressure injury this should include wound pain assessment. (2)

The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that changes these recommendations.

Patient assessment - Tools

There are three main risk assessment tools used in intensive care units; the Braden Scale, Waterlow Score and the Norton Scale. At this time “there is no high quality risk randomised control trial evidence which identifies that undertaking a structured risk assessment reduces the incidence of pressure injury” (4). In the critical care setting however, there are a number of studies that have investigated which pressure risk assessment tool is the most appropriate to use in the intensive care unit.

Due to the nature of risk assessment tools, it is difficult to interpret some results of the studies including the specificity and the positive predictive value as these results are influenced by the interventions used when a patient is identified as being at risk of developing a pressure injury. When compared to the Waterlow Score and the Norton Scale, the Braden Scale (1, 2) showed greater reliability at identifying which patients would develop a pressure injury. The negative predictive values for the Braden Scale were also higher than for both the Waterlow and the Norton Scales. The area under the receiver operator curve was also greater in the Braden Scale, recording fair to good results in the area under the curve when compared (See Appendix 4 Risk assessment tools - sensitivity and specificity).

Common pressure injury locations, front
Common pressure injury locations, back

Grading of recommendations

Grade of recommendation Description
A Body of evidence can be trusted to guide evidence
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provides some support for recommendation/s but care should be taken in its application
D Body of evidence is weak and recommendation must be applied with caution
Consensus Consensus was set as a median of ≥ 7
Grades A–D are based on NHMRC grades (2)


  1. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, Alvarez-Nieto C. Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs. 2006;54(1):94-110.
  2. Serpa LF, Santos VL, Campanili TC, Queiroz M. Predictive validity of the Braden scale for pressure ulcer risk in critical care patients. Rev Lat Am Enfermagem. 2011;19(1):50-7.
  3. Australian Wound Management Association. Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. Australian Wound Management Association. 2011.
  4. Moore ZE, Cowman S. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database Syst Rev. 2008;16(3).


The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.