5.2 Risk Assessment Tools & Risk Stratification
Key Takeaways
- The Braden Scale scores six subscales (sensory perception, moisture, activity, mobility, nutrition, and friction and shear) for a total of 6 to 23; lower scores mean higher risk, with common bands of 15–18 mild, 13–14 moderate, 10–12 high, and 9 or less very high risk.
- A risk score supplements clinical judgment rather than replacing it; guidelines recommend a structured risk assessment that also considers skin status, perfusion, diabetes, medical devices, and prior pressure injury.
- The IWGDF 2023 guidance stratifies diabetic foot ulcer risk: 0 (no loss of protective sensation or PAD, screen yearly), 1 (LOPS or PAD, every 6 to 12 months), 2 (LOPS plus PAD, or either plus foot deformity, every 3 to 6 months), and 3 (LOPS or PAD plus prior ulcer, amputation, or end-stage renal disease, every 1 to 3 months).
- Children need pediatric tools: the Braden QD adds items for tissue perfusion and oxygenation, number of medical devices, and repositionability, reflecting how often pediatric pressure injuries are device-related.
- Prognostic risk factors for delayed healing include larger wound area, longer wound duration, deeper tissue involvement, ischemia, infection, poor glycemic control, smoking, malnutrition, and nonadherence to offloading or compression.
5.2 Risk Assessment Tools & Risk Stratification
Core Clinical Principle: Risk assessment finds the patients most likely to develop a wound or fail to heal, so prevention resources go where they matter. Validated scales add structure and consistency, but each score must be paired with a skin inspection, clinical judgment, and a prevention plan that addresses every low subscale.
The CWSP outline lists risk assessment in the Assessment and Diagnosis domain, and identifying patient risk factors and prescribing preventive measures are listed tasks. Expect questions that ask you to score a scale, interpret the result, and choose a matching intervention.
The Braden Scale for Pressure Injury Risk
| Subscale | Score Range | What a Low Score Means | Matching Intervention |
|---|---|---|---|
| Sensory perception | 1–4 | Cannot feel or report discomfort | Scheduled repositioning, frequent skin checks |
| Moisture | 1–4 | Skin constantly moist from incontinence, sweat, or drainage | Continence care, barrier products, moisture-wicking linens |
| Activity | 1–4 | Bedfast or chairfast | Pressure redistribution surfaces, mobilization plan |
| Mobility | 1–4 | Cannot change position independently | Turning schedule, lateral tilt, heel offloading |
| Nutrition | 1–4 | Poor intake | Dietitian referral, supplements |
| Friction and shear | 1–3 | Slides down in bed, needs full assistance to move | Lift sheets, head of bed at 30 degrees or less when possible, trapeze, silicone foam dressings |
Totals range from 6 to 23. Commonly used bands are 15–18 mild (at risk), 13–14 moderate, 10–12 high, and 9 or less very high risk. Many facilities use 18 as the at-risk threshold for older adults or people with darker skin tones, where early injury is harder to see.
Worked example: A patient who responds only to painful stimuli (sensory 2), is often moist (moisture 2), is chairfast (activity 2), is very limited in mobility (mobility 2), has adequate intake (nutrition 3), and slides down in bed (friction and shear 1) scores 2 + 2 + 2 + 2 + 3 + 1 = 12, high risk.
Other Pressure Injury Scales
| Scale | Items | Direction | At-Risk Threshold |
|---|---|---|---|
| Norton | Physical condition, mental condition, activity, mobility, incontinence (each 1–4) | Lower = higher risk | 14 or less |
| Waterlow | Build and weight, skin type, sex and age, continence, mobility, appetite, special risks | Higher = higher risk | 10 or more at risk; 15 or more high; 20 or more very high |
| Braden QD | Mobility, sensory perception, friction and shear, nutrition, tissue perfusion and oxygenation, number of medical devices, repositionability and skin protection | Higher = higher risk | 13 or more indicates risk; validated from preterm infants to 21 years in acute care |
Scales predict risk only moderately well, and structured risk assessment has not been shown to reduce pressure injury incidence by itself. The international pressure injury guideline therefore recommends a comprehensive risk assessment that includes the scale plus skin and tissue inspection, perfusion, diabetes, medical devices, previous pressure injuries, body temperature, and the patient's general condition, repeated on admission, after any significant change, and at regular intervals.
Diabetic Foot Risk Stratification
The International Working Group on the Diabetic Foot (IWGDF) 2023 guidelines use loss of protective sensation (LOPS), peripheral artery disease (PAD), foot deformity, and history to set screening intervals:
| IWGDF Risk Category | Characteristics | Screening Frequency |
|---|---|---|
| 0 – Very low | No LOPS and no PAD | Once a year |
| 1 – Low | LOPS or PAD | Every 6 to 12 months |
| 2 – Moderate | LOPS + PAD, or LOPS + foot deformity, or PAD + foot deformity | Every 3 to 6 months |
| 3 – High | LOPS or PAD plus one or more of: history of foot ulcer, lower-extremity amputation (minor or major), or end-stage renal disease | Every 1 to 3 months |
High-risk patients benefit from therapeutic footwear that reduces plantar pressure, structured education, treatment of pre-ulcerative lesions (callus, blisters, fissures), and, for selected patients, at-home foot temperature monitoring to detect inflammation before an ulcer forms.
Risk Factors for Delayed Healing and Recurrence
| Category | Examples |
|---|---|
| Wound factors | Larger area, longer duration, greater depth, exposed bone or tendon, necrotic tissue, infection |
| Perfusion | PAD, low toe pressure or TcPO2, smoking, edema |
| Host factors | Diabetes with poor glycemic control, kidney failure, malnutrition, immunosuppression, older age, obesity |
| Mechanical and behavioral | Unrelieved pressure, nonadherence to offloading or compression, limited mobility, poor footwear |
| Social | Low health literacy, food or housing insecurity, lack of transportation or caregiver support |
For venous leg ulcers, larger area and longer duration at first visit consistently predict slower healing. For diabetic foot ulcers, depth (probe to bone), ischemia, and infection predict amputation, which is why the WIfI and SINBAD systems combine them. After healing, recurrence risk is high: about 40% of diabetic foot ulcers recur within a year, so a healed foot is "in remission," not cured.
Turning Scores Into Plans
- Score the scale and inspect the skin at the same visit.
- Address each low subscale with a specific action, not just the total.
- Document the score, the plan, and the date of reassessment.
- Reassess after surgery, transfer, a change in condition, or a new device.
Clinical Traps
Trap 1: A "Safe" Total With a Dangerous Subscale
A Braden total of 17 can hide a friction and shear score of 1 or a sensory score of 1. Target the subscale that is low.
Trap 2: Using Adult Tools for Infants
Adult scales miss device-related risk and the large, heavy head of an infant. Use a pediatric tool such as the Braden QD.
A 79-year-old man recovering from a hip fracture repair responds only to painful stimuli, is often moist from incontinence, is chairfast, makes only slight and infrequent position changes, eats about half of each meal, and slides down in bed despite repositioning. What is his Braden Scale score and risk category?
A 63-year-old woman with type 2 diabetes has loss of protective sensation on monofilament testing, palpable pedal pulses with a normal ankle-brachial index, and a healed plantar hallux ulcer from 2 years ago. Using the IWGDF 2023 risk stratification, what is her risk category and recommended foot screening interval?
A pediatric intensive care unit is choosing a pressure injury risk tool for infants and children, many of whom have nasal CPAP masks, pulse oximeter probes, and arterial lines. Which tool best fits this population?