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pressure ulcer risk scale

Use of risk assessment tools may be associated with lower risk for development of pressure ulcers. - persons with darker skin at risk of later detection of pressure injury - nonblanching erythema in darker-skinned populations may be difficult to detect [3,4] Commonly used scales 1) Norton scale* 2) Braden scale* (validated in non-white populations) [3] * most widely used tools to assess the risk of pressure injury development * contrast with Bates-Jensen Wound Assessment Tool the best instrument for monitoring healing of pressure injuries [3] Frequency of risk assessment: 1) more reliable if performed 24 hours after admission to health care setting (more reliable than upon admission) 2) Critical/acute acure - on admission, then 48 hours later, then every day 3) Medical/surgical - on admission, then 48 hours later, then every other day 4) long-term care - on admission, then 48 hours later, then weekly for 4 weeks, then quarterly (or routinely, more frequently) 5) home care - on admission, then 48 hours later, then weekly

Specific

Braden pressure ulcer risk scale Norton pressure ulcer risk scale Waterlow scale

General

numerical rating scale (NRS)

References

  1. Bates-Jensen B. In:Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  2. Bates-Jensen B. In:Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 25-28, 2002
  3. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  4. Oozageer Gunowa N, Hutchinson M, Brooke J et al. Pressure injuries in people with darker skin tones: a literature review. J Clin Nurs. 2018;27(17-18):3266-3275 PMID: 28887872 https://onlinelibrary.wiley.com/doi/10.1111/jocn.14062