Risk assessment starts when identifying risk factors during inspection of entire patients skin. Risk factors for pressure ulcers are classified into 2 groups, intrinsic or extrinsic.

Caregivers need to be educated about risk assessment and prevention. Patients should be inspected often to prevent pressure ulcers and identify them at early stages. 

The Braden Scale is the most commonly used tool for predicting pressure ulcer risk.

The Braden Scale assessment score scale:

  • Very High Risk: Total Score 9 or less
  • High Risk: Total Score 10-12
  • Moderate Risk: Total Score 13-14
  • Mild Risk: Total Score 15-18
  • No Risk: Total Score 19-23

Braden Assessment:

Wash and sanitize your hands before and after the assessment. 

Wear gloves, and change them as needed. 

Minimize exposure of body parts.

Provide privacy with a sheet or cover.

Ask for help to turn the patient as needed.

Know your facility’s policies and procedures.

Explain to the patient and family that you will be checking the patient’s entire skin.

Explain what you are looking for with each site.

Conduct the assessment in a private space.

Make sure the patient is comfortable.

*Pay special attention to 

Skin under and around medical devices or compression stockings

Skin to skin areas, such as the back of knees, palms, inner thighs, and buttocks

Any areas where the patient lacks sensation to feel pain

Had breakdown previously

Patient is getting epidural/spinal pain medicines

Bony prominences such as heels

Braden Risk Factors

  • Incontinence
  • Obesity
  • Edema
  • Anemia; hypoxemia
  • Poor hygiene
  • Exposure to chemicals 
  • Poor nutrition; decreased lean body mass
  • Diabetes mellitus
  • Decreased mobility, immobility, or paralysis
  • Cardiovascular disorders
  • Increased moisture or dryness
  • Use of medical devices
  • Prolonged procedures or surgery
  • Smoking
  • Advanced age
  • Corticosteroids
  • Impaired awareness
  • Decreased sensation
  • Increased metabolic demand

5 Parameters of Comprehensive Skin Assessment for Bed Sores

1. Temperature

2. Turgor

3. Color

4. Moisture

5. Skin integrity

Parameter 1: Skin Temperature

• Palpate with your hand to assess  and feel skin temperature.

• Skin warmth or coolness can indicate skin damage.

Parameter 2: Skin Turgor

• Skin normally  should return to its original state quickly when stretched.

• Can you “tent” the skin?

• Skin may be slow to return to its original shape in older and/or dehydrated patients.

Parameter 3: Skin Color

• Compare close areas of skin for color.

• Blanchable vs. nonblanchable erythema

• Purple or bruised looking skin

• Paper-thin skin

• Dark or reddened areas

• Darkly pigmented skin will not blanch.

Parameter 4: Skin Moisture

Moisture-associated skin damage:

• Skin can be dry or damaged from too much wetness.

• Etiology can be incontinence, urine, stool, or both, wound exudate, perspiration, including patients with a fever, between skin folds, ostomy or fistula that leaks.

*Make sure to get the etiology so you can treat the cause appropriately.

  Parameter 5: Skin Integrity

• Skin should be intact with no open wounds

• If skin is not intact, identify the cause of the skin integrity problem.

Special Notes:

Skin assessment requires a specific focus by staff. Must be standardized and ongoing.

How frequent you perform a comprehensive skin assessment depends on the needs of the unit.

• Can be as often as every shift. Is most often daily and when the patient is newly admitted, moved to a different level of care, transferred, or discharged.
You can easily integrate skin assessment into the normal workflow each time you:

• Check the patient’s ears for pressure areas from tubing if they are on oxygen

• Check bowel sounds, look at skin folds

•  Reposition the patient in bed, check the back of the patient’s head

•  Check IV sites, look at the patient’s elbows, wrists, and arms

•  Lift the patient or provide any care, check all exposed skin, especially on their bony prominencesRemove any attached equipment, check adjacent skin

• Check the patient’s shoulders, back, and sacral/coccyx region when listening to lung sounds

• Check a male patient’s catheter, check penis

• Position pillows under the patient’s calves, check the heels, feet and between toes

Documenting Results for Bed Sores

• Document any results of comprehensive skin assessment in each patient’s medical record even if there are no problems. 

  • Have a standardized place to record results in the medical record
  • Braden Scale documentation 
  • Keep a unit wide log

• Include results in all shift reports

• Make sure results are easy to access

Bed Sores or Pressure Ulcer Management

Measures to prevent pressure injury:

  • Use a risk-assessment scale, such as the Braden Scale, to identify actions that can modify the risk for pressure injury formation
  • Ensure meticulous skin care
  • Prevention

     -Prevention of pressure injuries has two main components:

  • Identification of patients at risk 
  • Interventions designed to reduce the risk

General Principles of Wound Assessment and Treatment:

Wound care treatment is divided into nonoperative and operative

  • For stage 1 and 2 pressure injuries, wound care is usually conservative and nonoperative.
  • For stage 3 and 4 lesions, surgical intervention (flap reconstruction) may be required. 
  • Approximately 70%-90% of pressure injuries are superficial and heal by second intention 

Successful medical management of pressure injuries:

  • Adequate débridement of necrotic and devitalized tissue 
  • Control of infection 
  • Meticulous wound care
  • Reduction of pressure 

If surgery of a pressure injury is indicated, medical status of patient must be optimized before reconstruction of wound is attempted. General measures for optimizing medical status include the following:

  • Maintenance of adequate blood volume 
  • Correction of anemia 
  • Maintenance of the cleanliness of the wound and surrounding intact skin 
  • Control of spasticity 
  • Nutritional support as appropriate 
  • Cessation of smoking 
  • Adequate pain control 
  • Management of urinary or fecal incontinence as appropriate 
  • Management of bacterial contamination or infection 

Additional nonsurgical treatment measures include the following:

•          Use specialized pressure-reducing surfaces to decrease pressure.       

• Offload heels (lift heels off of the bed to relieve pressure).

• Place a polyurethane dressing on the sacrum.

•          Wound care and application of appropriate dressings, as ordered

•          Whirlpool baths

•          Negative-pressure wound therapy for difficult wounds

• Venous thromboembolism (VTE) prophylaxis if the resident is hospitalized

• Hyperbaric oxygen therapy

• Electrical stimulation

• Consultation with a wound care specialist

• Control of incontinence and thorough perianal care

• Pressure reduction – Repositioning and use of support surfaces

• Wound management – Débridement, cleansing agents, dressings, and antimicrobials

• Cleanse skin promptly after episodes of incontinence and use a pH-balanced skin cleanser and a moisturizer daily. 

Surgical interventions:

  • Diversion of the urinary or fecal stream 
  • Release of flexion contractures 
  • Debridement of necrotic tissue  
  • Direct closure
  • Flap reconstruction
  • Skin grafting
  • Amputation

Diet Can Make a Difference for Patients or clients suffering from bed sores:

• Nutritional status assessment

• Balanced diet that’s high in protein and iron

• Vitamin C (unless contraindicated) to promote collagen synthesis and tensile strength

• Vitamin A to promote epithelization and fibroblast stimulation

• Zinc to aid protein synthesis

• Copper to promote collagen production and cross-linking

• Manganese to promote collagen and ground substance formation

• Adequate fluid intake to maintain hydration

• Enteral or parenteral nutrition if necessary


• As tolerated

• Active and passive range-of-motion (ROM) exercises

• Frequent turning and repositioning

• Offloading to reduce pressure

Medications for Bed Sores

• Enzymatic ointments to dissolve necrotic tissue

• Antibiotics to treat bacterial infections

• Topical antimicrobials for non-healing pressure injuries

• Skeletal muscle relaxants to relieve spasticity 

• Topical lidocaine for procedural pain relief

• Non-opioid or opioid analgesics for pain control


Pressure Injuries (Pressure Ulcers), Long Term Care:




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