Module 2
Pressure Injury Care and Prevention
Pressure Injury Risk Assessment, Classification and Staging
Risk Assessment, and the use of Risk Assessment Scales
Current pressure injury preventive measures require a comprehensive risk assessment of all patients admitted to an acute care service, which is an essential component of clinical practice.1 Pressure injury risk assessment tools are usually used to identify individuals at risk of developing a pressure injury.2 The most common validated tools used for pressure injury risk assessment in adult populations are:
- the Braden Scale for Predicting Pressure Sore Risk (Braden Scale)
- the Norton Scale
- the Waterlow Score.
There is, however, no reliable evidence to suggest that the use of structured and systematic pressure injury risk assessment tools reduces the incidence, or severity of pressure injury when compared to risk assessment using clinical judgement.3 The clinical judgement concept integrates 'all reasoning tasks and actions performed by health professionals to describe and assess a health condition of interest. It describes the sum of cognitive actions carried out by health professionals to interpret and synthesize information to derive a diagnosis and management plan for an individual'.4, page 61
The authors of the recent systematic review 5 concluded that risk status varied across different methods of pressure injury risk assessment, and it was unclear what impact this had on preventive intervention use. Also, the risk status was not well linked to preventive interventions in the reviewed studies. The authors concluded that regardless of whether pressure injury risk assessment is undertaken using a tool or not, it is essential that implementation of preventive interventions follows risk assessment as per risk identified, otherwise patient safety may be compromised. The authors recommend pressure injury risk assessment using a structured assessment tool as the gold standard, given the lack of evidence supporting the effectiveness of clinical judgment alone, and suggest that other methods be compared against this standard.5
The year 2019 International clinical practice guideline on prevention and treatment of pressure injuries4 recommended a comprehensive view of the conditions and methods of risk assessment. The two-step approach as a recommendation for good practice was introduced. The first step involves an initial screening for all individuals admitted to the care service, followed by a comprehensive risk assessment for those identified as at risk during the screening process as explained by Balzer and associates.6 The Pressure Injury Risk Section content in the live 2025 guidelines1 is coming soon.
People rely far too much on a tool instead of using their clinical judgement. I always tell people that your clinical judgement will overrule anything because you get a score that brings a patient at a low risk by using some of these validated tools… I think that you don’t look at going to surgery as a change in a person’s condition or having a fall. So, I think we let ourselves down in not repeating the assessment.
This study assessed whether using structured and systematic pressure ulcer risk assessment tools, reduces the risk of pressure ulcers: Moore ZEH, Patton D. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews 2019, Issue 1. Art. No.: CD006471. DOI: 10.1002 / 14651858.CD006471.pub4.
The authors of this study conducted a systematic review, comparing pressure injury risk assessment outcomes using a structured assessment tool versus clinical judgement: Lovegrove J, Ven S, Miles SJ, Fulbrook P. Comparison of pressure injury risk assessment outcomes using a structured assessment tool versus clinical judgement: A systematic review. J Clin Nurs. 2023 May;32(9-10):1674-1690. doi: 10.1111/jocn.16154. Epub 2021 Dec 1. PMID: 34854158.
Introduction to the SSKIN Care Bundle and the aSSKINg Framework
The SSKIN (Surface, Skin inspection, Keep your patients moving, Incontinence/moisture, Nutrition/hydration) care bundle has been developed by the National Health Service (NHS) UK, and is widely used in clinical practice.8
The videoclip below, ‘Stop the Pressure’ is a two-minute animation developed by NHS East of England to explain the SSKIN bundle that may be of practical help for you and your colleagues.
In 2018, the SSKIN acronym was upgraded to aSSKINg framework (Figure 1), by adding two important preventive elements: ‘a’ for ‘assess risk’ and ‘g’ for ‘giving information’.
Figure 1: aSSKINg Framework. NHS Stop the Pressure.
One of my biggest things was the risk assessment tools, so nurses were using the Braden; and I felt that for four years of the audit they were getting the same results. The audit was showing that we had low-risk patients developing pressure injuries so I felt that that tool was failing us. So, we incorporated the SSKIN bundle into our daily plan of care, which was magical.
Pressure Injury Classification
The following classification of pressure injury was developed by European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan-Pacific Pressure Injury Alliance4
Stage I – non-blanchable erythema
Stage II – partial thickness skin loss
Stage III – full thickness skin loss
Stage IV – partial thickness tissue loss
Unstageable – depth unknown
Suspected Deep Tissue Injury – depth unknown.
Figure 2:
Pressure Injury Category/Stages: photographs and illustrations 1
Main Pitfalls in Clinical Staging of Pressure Injury
In clinical practice, sometimes, it is difficult to identify a clinical stage of pressure injury in a systematic fashion.2 The most common pitfalls in diagnostics and differential diagnostics of pressure injury are:
Stage 1 pressure injury can be misdiagnosed as Incontinence Associated Dermatitis (IAD). The most important diagnostic point is patients’ history: if the patient is not incontinent, the condition is not IAD. There are other parameters to be considered, including location, shape and edges, presentation and depth, and clinical symptoms (Table 1).
Suspected deep tissue injury could be mistakenly classified as pressure injury Stage 1 or 2. Bruising (the localised area of discoloured intact skin is purple or maroon) indicates suspected deep tissue injury.4
Suspected deep tissue injury may be difficult to detect in people with darker skin tones. According to the Clinical Practice Guidelines,4 when classifying pressure injury in patients with darkly pigmented skin, clinicians should rely on “assessment of skin temperature, sub-epidermal moisture, change in tissue consistency and presence of skin pain rather than identification of erythema”.
If you are not sure about the presence and stage of a pressure injury,
consult with a suitably qualified colleague.
Definitely deep tissue injuries get still classified as Stage 1s or 2s, so that’s probably the biggest problem we have out there, and IAD [Incontinence Associated Dermatitis] being called pressure injuries. They’re probably the two biggest ones that I see are the most problematic and probably the most work for us.
Table 1. Differentiation between pressure injury and IAD (adapted from Ousey et al)7.
Parameter |
Pressure Injury |
Incontinence Associated Dermatitis |
|---|---|---|
| History |
Exposure to pressure/shear |
Urinary or/and faecal incontinence |
| Location |
Usually over a bony prominence or associated with location of a medical device |
Affects perineum, perigenital area, buttocks, gluteal fold, medial and posterior aspects of upper thighs; lower back; may extend over bony prominence |
| Shape/edges |
Distinct edges or margins |
Affected area is diffuse with poorly defined edges/may be blotchy |
| Presentation/depth |
Presentation varies from intact skin with non-blanchable erythema to full-thickness skin loss Base of wound may contain nonviable tissue |
Intact skin with erythema (blanchable or non-blanchable), with/without superficial, partial-thickness skin loss |
| Symptoms | Pain |
Pain, burning, itching, tingling |
|
Other |
Secondary soft tissue infection may be present |
Secondary superficial skin infection (e.g. candidiasis) may be present |
Practical resource developed by Wounds International (2025):
Incontinence-associated dermatitis (IAD): Optimising skin barrier function, a 3-step approach could be accessed on their website:
or downloaded from: https://woundsinternational.com/wp-content/uploads/2025/05/HAR25_ME_MOLICARE_WINT_Web.pdf
Webinar – ICU perspectives in pressure injury risk assessment and staging
Below you will find a webinar that captures recent research and evidence-based practices undertaken by leading clinicians and researchers from Alfred Health and Monash Partners and on pressure injury risk assessment and staging in acute health services. Frontline clinicians from The Alfred hospital Intensive Care Unit describe their experience with:
- The SSKIN care bundle
- Pressure injury risk assessment tools in care planning
- The key pitfalls in pressure injury staging.
Test your pressure injury staging skills by accessing practical resources developed by Medscape by signing up for a free account. Bedridden Breakdown: Classifying Pressure Injuries. Can you properly classify these pressure injuries? Located at: https://reference.medscape.com/slideshow/classifying-pressure-injuries-6005748
Please refer to the following study on nurses' experiences of hospital-acquired pressure injury prevention: Team V, Bouguettaya A, Qiu Y, Turnour L, Banaszak-Holl JC, Weller CD, Sussman G, Jones A, Teede H. Nurses' experiences of hospital-acquired pressure injury prevention in acute healthcare services in Victoria, Australia: A qualitative study using the Theoretical Domains Framework. Int Wound J. 2024 Jul;21(7):e14956. doi: 10.1111/iwj.14956.
References
- European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan-Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. EPUAP/NPIAP/PPPIA:2025. https://www.internationalguideline.com/the-international-guideline#about
- Weller, CD, Gershenzon, ER, Evans, SM, Team, V, McNeil, JJ. Pressure injury identification, measurement, coding, and reporting: Key challenges and opportunities. Int Wound J. 2018; 15: 417– 423.
- Moore ZEH, Patton D. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews 2019, Issue 1. Art. No.: CD006471. DOI: 10.1002/14651858.CD006471.pub4.
- European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan-Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed). EPUAP/NPIAP/PPPIA:2019.
- Lovegrove J, Ven S, Miles SJ, Fulbrook P. Comparison of pressure injury risk assessment outcomes using a structured assessment tool versus clinical judgement: A systematic review. J Clin Nurs. 2023 May;32(9-10):1674-1690. doi: 10.1111/jocn.16154. Epub 2021 Dec 1. PMID: 34854158.
- Balzer, K., Carville, K., Ayello, E. A., Berlowitz, D., Carruth, A., Chang, Y. Y., Cox, J., Creehan, S., Haesler, E., Jan Kottner, Moore, Z., Ngan, H. L., & Cuddigan, J. (2025). From Screening to Full Risk Assessment in Pressure Injury Prevention: Targeting the Right Care to the Right Patients. Advances in skin & wound care, 38 (10), 511–518. https://doi.org/10.1097/ASW.0000000000000377
- Ousey K, O’Connor L, Doughty D, Hill R, Woo K. Incontinence-associated dermatitis Made Easy. London: Wounds International 2017; 8(2). Available from: www.woundsinternational.com
- Whitlock J. SSKIN bundle: Preventing pressure damage across the health-care community. British Journal of Community Nursing. 2014; 18: suppl 9: s32-39.