Pressure Injury Risk Assessment Factors: What Are We Looking For, and Why?

What would pressure injury prevention look like in an ideal world?

Each of our patients would receive unlimited resources geared toward every aspect of pressure injury prevention: top-of-the-line technology including mattresses, chairs, heel-offloading devices and cushions designed to prevent pressure injuries. In addition, every patient would be paired with a particular staff member dedicated to repositioning, encouraging mobility and keeping the patient clean and dry.

Resource Allocation

As beautiful (and successful!) as that dream sounds, in reality, our resources are limited. In a world with finite resources, explains Prof. Jane Nixon of the Leeds Institute of Clinical Trial Research, risk assessment tools play an important role. They help us identify how and where we should allocate our available resources to most effectively minimize the number and severity of pressure injuries.

Patients with higher risk should receive not only more resources but also resources which are tailored to address their specific risk factors.

Pressure Injury Risk Factors

Risk factors fall into two categories: external conditions to which patients are exposed, and intrinsic conditions that determine how the patient is affected by the external conditions. External conditions can be changed. Identifying them enables us as caregivers to take steps to change them, if need be.

External conditions include

• Pressure
• Friction
• Shear

These mechanical boundary conditions are the forces that create pressure injuries. The more exposure the patient has, the greater the risk of injury.

Some physical conditions lead to greater exposure to these external forces. In these cases, we as caregivers need to be extra vigilant to protect our patients from these forces – as they don’t have the awareness or ability to protect themselves.

These physical conditions include:

• Immobility – patients who are immobile are inherently exposed to prolonged pressure, while repositioning patients suffering from immobility exposes them to friction and shear.
• Numbness – patients cannot identify and respond to the forces of pressure, friction and shear.

Intrinsic conditions most often cannot be changed. Identifying them enables us to make better decisions about how to compensate for them.

• Edema
• Fragile skin
• Poor nutrition
• Exposure to moisture or incontinence
• Collagen and elasticity loss (due to advanced age)
• Poor blood supply to the skin (often occurring in intensive care units since the body focuses blood supply around the central organs at the expense of the peripheral circulation)

All of the above intrinsic factors make the skin more vulnerable to even minor mechanical stressors. While fragile skin and incontinence are beyond our capability to “fix,” we can compensate for it.

Compensating with Awareness and Resource Allocation

Just being aware that the patient is at risk and how they are at risk is a giant step in minimizing that risk. As caregivers, we can compensate by using appropriate techniques for the specific situation at hand.

A 22-year old paralyzed in an accident will face greater risk from pressure (she can’t move, or even feel discomfort from the pressure and ask someone to help her move) but less risk from friction and shear (her skin is young, elastic and receiving proper nutrients). For her, we should be more concerned about getting her repositioned at the appropriate frequency, and less concerned about the friction effect the frequent repositioning will have on her skin. For a 92-year old with extremely fragile skin and edema, and limited (but not loss of) mobility, the concerns and conclusions will – and should – be different.

Mattresses, cushions, offloading devices, dressings – knowing which equipment will make the greatest impact on any given situation is critical.

Compensating with Care

Even if one could spout the pressure injury risk factors by heart if woken up from a deep sleep – information by itself will not help any patient. You need to care enough to apply it, care enough to keep your eyes open, care enough to find and manage the resources in the best interests of your patient’s health.

Fortunately, we’re caregivers. It’s a trait we have in abundance and it’s why we selected this profession. Take the risk factor information and awareness; add your caring heart. If you do so, then even in the real world, with limited resources, you’ll come as close to ideal pressure injury prevention as is possible.