Despite the well-known personal and financial tolls infl icted by pressure
ulcers, predicting exactly who will suffer skin breakdown and who will not is
still being studied. A 2005 report by Yu-ying Chen, MD, Ph.D., University of
Alabama at Birmingham, et al, discussed spinal cord injury (SCI) patients who
were observed for pressure ulcer development over periods of seven to 16 years.
In addition to finding pressure sore development more common in SCI patients
who were older or had histories of skin breakdown — known to be higher-risk
factors — the study also found pressure sores to be more prevalent in
patients who were black, single or unemployed. The researchers’ conclusion:
“These results highlight the need for research into factors that contribute
to the increasing pressure ulcer prevalence.”
Developing an Assessment Checklist
The National Pressure Ulcer Advisory Panel defines pressure ulcers as a “localized
injury to the skin and/or underlying tissue usually over a bony prominence,
as a result of pressure, or pressure in combination with shear and/or friction.”
While not all contributing forces are clearly understood, the Braden Scale for
Predicting Pressure Sore Risk lists six factors to check for:
- Sensory perception: “The ability to respond meaningfully to pressure-related
discomfort,” via body language or verbal complaints. Also includes whether
patient has any sensory impairments that preclude being able to feel pain.
- Moisture: How often skin is moist due to perspiration, urine, etc.
- Activity: Whether the patient is a frequent ambulator, walks occasionally,
can sit in a chair or wheelchair, or is confined to bed.
- Mobility: “The ability to change and control body position.”
Includes how often the patient can change position, how significant the position
changes are and whether the patient needs assistance.
- Nutrition: The patient’s “usual food intake,” whether
by mouth or by tube feeding or IVs.
- Friction & shear: How often the patient is exposed to friction/shear
because of an inability to completely lift and bear body weight while moving
and transferring. Includes whether moving and transfers are done independently
or require assistance.
The Norton Scale, designed to predict pressure sore occurrence in elderly
patients, includes other factors, such general physical condition, mental state,
food intake, fluid intake and incontinence.
Other Factors to Consider
In a presentation titled Principles of Pressure Management in conjunction
with the Rehabilitation Engineering & Research Center on Wheeled Mobility
(RERCWM), Douglas A. Hobson, Ph.D., says, “Immobility is the greatest
risk factor” for pressure sore occurrence.
That means that some patient populations traditionally thought to be at relatively
low risk — for instance, patients who have sensation and bariatric clients
who have more tissue over bony prominences — may still be at high risk
if they are not able to reposition themselves completely and often enough. Immobile
patients with sensation may still face skin breakdown if they’re unable
to voice their discomfort or unable to find someone to assist with frequent
and significant repositioning. And bariatric patients who find it difficult
to fully lift their body weight and resort therefore to sliding across surfaces
can be prone to shear injuries.
Says Hobson, “(There) does not seem to be any relationship between body
type and deep ulcers. Surface friction may increase with heavier people.”
Among other contributing factors, Hobson lists an “infectionincreased
metabolic rate,” noting that “higher oxygen demand endangers ischemic
tissue.” Aging, he says, can also increase risk due to the natural loss
of skin elasticity along with muscle atrophy. Impact injuries and abrasions
can also result in higher risk.
Chen’s 2005 study found pressure sores more prevalent in SCI patients
who had complete injuries, or had been rehospitalized or admitted to nursing
homes, though the level of the injury was found to have “no significant
That 2005 report also found increased risk for SCI patients who reported less
than a high school education, which brings up a good general point: It’s
tougher to fight a condition if you don’t understand it. Education can
be one of the best tools to help patients and caregivers to make changes in
lifestyle, nutrition, transfer processes, etc., to lower pressure sore risk.
The right education can also help them to regularly check for and quickly
identify early-stage pressure ulcers so they can get treatment before more damage
is done. See the sidebar for ways you can empower seating & mobility users
to help themselves.
Pressure Ulcer Education
- The Journal of the American Medical Association (JAMA) offers a pdf aimed
at patients with high pressure sore risk. Diagrams show the areas of the body
commonly at risk of skin breakdown, along with prevention and treatment info.
Download JAMA’s “Patient Page” on pressure ulcers by going
- The Spinal Cord Injury Information Network advocates lowering pressure
sore risk by maintaining healthy skin. This article says up to 80 percent
of SCI patients will develop pressure sores, but adds that 95 percent of them
are preventable. Go to spinalcord.uab.edu/show.asp?durki=21486
to read the article; scroll to the bottom of the article to access a slideshow
(with photos) of the information.
- Download a pdf of the Braden Scale for Predicting Pressure Sore Risk at