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Predicting Pressure Injury Risk

By: Elizabeth A. Ayello, PhD, RN, ACNS- BC, CWON, FAAN; Excelsior College School of Nursing

WHY: Pressure injuries (PIs) occur frequently in hospitalized, community-dwelling and nursing home older adults, and are serious problems that can lead to sepsis or death. Incidence rates for PIs are 2.8% to 9% in acute care with higher rates up to 23.9% in ICU patients, 8.5% in long term acute care (LTAC), 3.6% to 59% in long term care (LTC), and 4.5% to 6.3% in home care. A key to prevention is early detection of all of an individual’s risk factors which includes using a valid and reliable risk assessment tool and timely implementation of prevention interventions.

BEST TOOL: The Braden Scale for Predicting Pressure Sore Risk©, available in several languages, is among the most widely used tools for predicting the development of PIs. Assessing risk in six areas (sensory perception, skin moisture, activity, mobility, nutrition and friction/shear), the Braden Scale assigns an item score ranging from one (highly impaired) to three/four (no impairment). Summing risk items yields a total overall risk, ranging from 6-23. Scores 15 to 18 indicate at risk, 13 to 14 indicate moderate risk, 10 to 12 indicate high risk, ≤ 9 indicate very high risk. However, do not only rely on the total score. Basing prevention protocols on low subscale scores are also recommended by Dr. Braden, National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP), and Pan Pacific Pressure Injury Alliance (PPPIA), and required by Centers for Medicare and Medicaid Centers (CMS) in Tag F 314 guidance for long term care and the Resident Assessment Instrument (RAI) Manual. Targeting specific prevention interventions that address low risk subscale scores can offer effective resource use. Use the Braden Scale scores as part of comprehensive structured assessment that includes observation of the person’s skin status and recognition of an individual’s other additional relevant risk factors (such as existing or previous PI, vascular disease, diabetes, alterations in blood pressure (either high or low) perfusion and oxygenation, poor nutritional status, increased skin moisture including from urinary, fecal incontinence, increased body temperature, advanced age, hematological measures, and general health status), as well as clinical decision making to determine pressure injury risk (NPUAP, EPUAP, and PPPIA, 2014).

TARGET POPULATION: The Braden Scale is commonly used with medically and cognitively impaired older adults.  It has been used extensively in acute, home, and institutional long term care settings. A version specific to home care may be downloaded from  National and international clinical guidelines recommend that a structured risk assessment should be done as soon as possible but within 8 hours of admission or at first contact with health professional or first visit in the community setting (NPUAP, EPUAP, and PPPIA, 2014). Risk assessment should be repeated as often as required based on the individual’s acuity or significant change in their condition (NPUAP, EPUAP, and PPPIA, 2014).

VALIDITY AND RELIABILITY: The ability of the Braden Scale to predict the development of PIs (predictive validity) has been tested extensively. Inter-rater reliability between 0.72 and 0.95 is reported. The tool has been shown to be equally reliable with Black and White individuals. Sensitivity ranges from 83-100% and specificity 64-90% depending on the cut-off score used for predicting PI risk. 

STRENGTHS AND LIMITATIONS: When utilized correctly and consistently, the Braden Scale, as part of a structured risk assessment process that includes skin status assessment and identification of other relevant risk factors, helps identify the associated risk for PI so that appropriate preventive interventions may be implemented in a timely way. 


Best practice information on care of older adults:

Braden Scale. Last accessed August 25, 2016

Baranoski, S., & Ayello, E.A. (2016). Wound care essentials: Practice principles (4th edition). Philadelphia PA: Wolters Kluwer Health.

Bergstrom, N., & Braden, B.J. (2002). Predictive validity of the Braden Scale among Black and White subjects. Nursing Research, 51(6), 398-403.

Bergstrom, N., & Braden, B.J., Laguzza, A., & Holman, V. (1987). The Braden Scale for predicting pressure sore risk. Nursing Research, 36(4), 205-210.

Chou, R., Dana, T., Bougatsos, C., Blazina, I., Starmer, A.J., Reitel, K., & Buckley, D.I. (2013). Pressure ulcer risk assessment and prevention: A systematic comparative effectiveness review. Annals of Internal Medicine, 159(1), 28-38. doi: 10.7326/0003-4819-159-1-201307020-00006

Delmore, B., Lebovits, S., Suggs, B., Rolnitzky, L., & Ayello, E.A. (2015). Risk factors associated with heel pressure ulcers in hospitalized patients. Journal of Wound, Ostomy & Continence Nursing, 42(3), 242-248.

Garcia-Fernandez, F., Pancorbo-Hidalgo, P., & Soldevilla, J. (2014). Predictive capacity of risk assessment scales and clinical judgment for pressure ulcers. Journal of Wound, Ostomy & Continence Nursing, 41(1), 1-11.

National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP), and Pan Pacific Pressure Injury Alliance (PPPIA). (2014). Prevention and treatment of Pressure ulcers-Clinical Practice Guideline. Washington DC: NPUAP. Available at:

National Pressure Ulcer Advisory Panel Pressure Injury Stages and Definitions. Updated April 2016:

Pancorbo-Hidalgo, P., Garcia-Fernandez, F., Lopez-Medina, I., & Alvarez-Nieto, C. (2006). Risk assessment scales for pressure ulcer prevention: a systematic review. Journal of Advanced Nursing, 54(1), 94–110.

Pieper, B. with the National Pressure Ulcer Advisory Panel (NPUAP). (2012). Pressure ulcers: Prevalence, incidence, and implications for the future. Washington, DC: NPUAP.
Van Gilder, C., Amlung, S., Harrison, P., & Meyer, S. (2009). Results of the 2008-2009 International Pressure Ulcer Prevalence™ Survey and a 3-year, acute care unit specific analysis. Ostomy Wound Management, 55(11), 39-45.