Understanding Pressure Ulcer Risk Assessment Scales

Blog Post | Common Pressure Ulcer Assessment Tools and Scales

Pressure ulcers, also known as bedsores, are a significant concern in healthcare, particularly for individuals with limited mobility. Preventing these painful and potentially severe wounds starts with identifying those at risk.

This is where pressure ulcer risk assessment scales come in.

These tools help healthcare professionals evaluate a patient’s vulnerability to developing pressure ulcers and implement timely preventive measures.

Pressure ulcers represent a significant challenge in healthcare settings across the UK.

These painful injuries not only diminish patients’ quality of life but also place substantial financial burden on the NHS, with treatment costs estimated at £1.4-£2.1 billion annually—approximately 4% of total NHS expenditure. Identifying at-risk patients through systematic assessment is the cornerstone of effective prevention strategies.

In this blog, we’ll explore what these scales are, how they work, and why they’re essential in delivering high-quality care.

What Are Pressure Ulcer Risk Assessment Scales?

Pressure ulcer risk assessment scales are tools used by healthcare staff to check if a person is likely to get a pressure ulcer (also called a bedsore).

These tools look at things like how well the person can move, the condition of their skin, and their overall health. Each person gets a score, which helps carers decide what care is needed to stop skin damage.

Common Scales Used in Care

1. Braden Scale

Looks at:

How well the person can feel things
How wet or moist the skin is
How active the person is
How well they can move
What their food and drink is like
If there is any rubbing or sliding that could hurt the skin

2. Norton Scale

Looks at:

Physical health
Mental state (how alert they are)
Activity level
How well they can move
If they are wet from wee (incontinence)

3. Waterlow Score

Looks at:

Body size and weight
Skin type and problems
How well the person can move
If they can control their bladder and bowels
If they are eating well
Extra risks like nerve damage or poor nutrition

Each scale is a bit different, but they all help staff find out who is at high risk of pressure ulcers. This means carers can act early to keep the skin healthy and stop sores from forming.

Why Structured Risk Assessment Is Important for Pressure Ulcers?

A structured risk assessment is a careful way of checking if someone is at risk of getting a pressure ulcer (also called a bedsore or pressure injury). It helps carers take the right steps early to stop skin damage and keep people safe.

Structured risk assessment is vital for preventing and managing pressure ulcers (also called bedsores) in healthcare. It helps identify at-risk patients, evaluate key factors, and apply targeted prevention strategies.

1. Finds At-Risk Patients Early

Using tools like the Braden Scale, Norton Scale, or Waterlow Score helps carers find out who is most at risk. These tools look at things like movement, skin health, eating, and other health problems. Early checks mean early care.

2. Keeps Evaluations Consistent

Using standard tools ensures everyone on the healthcare team assesses risks the same way. This reduces mistakes and makes sure no risks are missed, even in busy settings like hospitals.

3. Guides Personalised Care

The scores help staff choose the right care. For example:

A person who can’t move well may need turning often.
Someone not eating enough may need food support.
This helps each person get care that fits their needs.

4. Improves Patient Health

Good risk assessments mean fewer pressure ulcers. This reduces problems like infections or longer hospital stays, keeping patients safer and healthier.

5. Following the Rules

Health services must do proper risk checks to meet laws and inspection standards. Using proper tools shows that care is safe and well-done.

6. Saves Money

Preventing pressure ulcers costs less than treating them. Treatment can involve long hospital stays, special beds, or surgery, which are expensive. Prevention is a smarter choice.

7. Better Teamwork and Records

Using a set method makes it easier for staff to write down the right information and work well together. This helps during shift changes or when moving someone to a new care setting.

8. Keeping Checks Up to Date

A person’s health can change. Risk assessments should be done again if things change, to make sure the care plan is still right.

Structured risk assessment is important for preventing pressure ulcers.

It helps healthcare staff find risks early, provide consistent care, and create care plans that meet each patient’s needs.
This leads to better safety, improved health outcomes, and ensures care meets required standards.
All healthcare providers should use structured risk assessments to support high-quality care.

What Are The Common Risk Assessment Scales Used in UK Healthcare?

In UK healthcare, several trusted risk assessment tools are used to find patients who may develop pressure ulcers (also called pressure injuries or bedsores). These tools help staff assess risk in a consistent way, plan prevention strategies, and follow national care standards. They support the guidelines set by the National Institute for Health and Care Excellence (NICE) and the NHS.

Waterlow Score

The Waterlow Score is one of the most commonly used tools in the UK to check a person’s risk of developing pressure ulcers. It was developed in the UK by Judy Waterlow in 1985.

The Waterlow Scale looks at many risk factors to assess a patient’s chance of developing pressure ulcers. Scores start at 10 or above for those at risk, and go up to 20 or more for patients at very high risk.

Each score level has its own recommended steps to help prevent pressure ulcers. Because it is detailed and thorough, the Waterlow Scale is often used in hospitals and acute care settings.

Factor Evaluated

It considers several factors, including:

Body build and weight
Skin condition
How well the person can move
Age and sex
Appetite
Bladder and bowel control (continence)
Special risks (like poor nutrition, nerve damage, or recent surgery or trauma)

How scoring works:

A score of 10 or more means the person is at risk
15 or more means high risk
20 or more means very high risk

Where it’s used:

You’ll find it used in hospitals, nursing homes, and community care.
It is supported by NICE because it gives a full picture of the person’s condition.

Strengths:

Very detailed and can be used with many different types of patients

Things to keep in mind:

It can seem a bit complex, so staff may need training to use it correctly

Braden Scale

The Braden Scale is a well-known tool used around the world. Many UK hospitals and care settings use it to check how likely someone is to develop a pressure ulcer.

The Braden Scale was created in the 1980s by Barbara Braden and Nancy Bergstrom. It helps healthcare staff find out if a patient is at risk of getting pressure ulcers. The scale has six parts. The total score you can get is between 6 and 23.

Factor Evaluated:

It checks six key areas:

Sensory perception (how well the person can feel pain or pressure).
Moisture (if the skin is often wet).
Activity (how active the person is).
Mobility (how well they can move).
Nutrition (what and how much they eat).
Friction and shear (if the skin is rubbing or being pulled).

How scoring works:

Scores range from 6 to 23.
Lower scores mean higher risk (a score of 12 or less = high risk).

Where it’s used:

It is often used in hospitals and long-term care, especially when care teams use electronic health records to track assessments.

Strengths:
Simple to use.
Based on strong evidence.
Quick to complete.

Things to keep in mind:

It doesn’t look deeply at other health problems (like the Waterlow Scale does), but it is still very dependable.

Norton Scale

The Norton Scale is one of the first tools made to check for pressure ulcer risk. Though it is older, some UK care settings still use it today.

The Norton Scale was developed by Doreen Norton in 1962. It is a risk assessment tool used to predict the likelihood of pressure ulcer in patients.

What it looks at:

It measures five key areas:

Physical condition (general health).
Mental condition (how alert or confused the person is).
Activity (how active they are).
Mobility (how well they can move).
Incontinence (if they have trouble controlling their bladder or bowels).

How scoring works:

Scores range from 5 to 20
A score of 14 or below means the person is at risk

Where it’s used:

Still seen in some community care settings or older care plans, but not as common today as the Waterlow or Braden scales.

Strengths:
Simple and fast to complete

Things to keep in mind:

It does not cover as many risk areas, so staff may need to use other tools alongside it.

PURPOSE-T

(Pressure Ulcer Risk Primary or Secondary Evaluation Tool)

PURPOSE-T is a newer tool made in the UK. It helps staff check both the risk of getting a pressure ulcer and assess any ulcers already present.

The PURPOSE-T tool (Pressure Ulcer Risk Evaluation) is a new method created by researchers at the University of Leeds.

Instead of using basic risk scores like older tools, it follows three clear steps:

Patient Details & Skin Check: Gather basic information and examine the skin.
Mobility Test: Assess how well the patient can move on their own.
Risk Factor Review: Look closely at issues that might lead to pressure ulcers.

What it looks at:

It includes several areas:

Mobility (how well the person can move)
Skin condition
Past pressure ulcers
Sensory perception (feeling pressure or pain)
Blood flow (perfusion)
Nutrition
Moisture (if the skin is often wet)

How scoring works:

Instead of giving a number, it uses a step-by-step pathway to decide if someone is:

Not at risk
At risk
High risk

Where it’s used:

More NHS services are now using PURPOSE-T. It follows NICE guidelines and focuses on person-centred care.

Strengths:

Modern and based on good research
Looks at the whole person, not just one area
Fits well with UK care standards

Things to keep in mind:

Staff need training to use the tool properly because it follows a decision-making process, not just scoring.

The Waterlow Score, Braden Scale, Norton Scale, and PURPOSE-T are the main tools used in the UK to check a person’s risk of getting pressure ulcers.

Waterlow and Braden are the most commonly used because they are well-known and backed by research.
PURPOSE-T is becoming more popular because it uses a modern and patient-focused approach.

These tools help staff find risks early, give consistent care, and follow UK care standards. This leads to better care and safer outcomes for patients.

Key Notes on Use in the UK

NICE Guidelines:

The National Institute for Health and Care Excellence (NICE) says staff should use a trusted pressure ulcer risk tool—like the Waterlow, Braden, or PURPOSE-T—within 6 hours of a patient arriving at a hospital or care setting.

Staff should do regular checks after that, especially if the patient’s health changes.

Link to Care Plans:

These tools are often part of electronic health records (EHRs). They help guide care using steps like the SSKIN bundle, which stands for:

Surface (use the right mattress or cushion)
Skin inspection (check skin regularly)
Keep moving (help the person change position often)
Incontinence (manage wet skin)
Nutrition (support healthy eating)

Training for Staff:

Nurses and care staff are trained to use these tools as part of pressure ulcer prevention. Training is often linked with record-keeping so staff can write clear, correct notes.

Local Differences:

Some NHS trusts or care homes may change how they use these tools. For example, they might use Waterlow when a patient first arrives and Braden to keep checking risk over time. This depends on the local policy.

Using Risk Assessment in Health Care

Risk assessment tools like the Waterlow Score, Braden Scale, Norton Scale, and PURPOSE-T are helpful for spotting who might get pressure ulcers. But to be useful, they must be used the right way.

How to Use Risk Assessments Properly

Assess patients as soon as they are admitted, then check regularly, based on your local policy.
Use the results to help make a care plan for each person—don’t just fill in the form and stop there.
Clinical judgement is still very important. Don’t rely only on the tool—use your own knowledge and experience too.
Staff must be trained to use these tools correctly and to understand what the results mean.

How to Use Pressure Ulcer Risk Assessment Tools Correctly

Using pressure ulcer tools the right way helps prevent harm and improves care. Here’s how to do it step by step:

1. Choose the Right Tool

Pick a tool that fits your care setting and the patient’s needs:

Waterlow Score – Good for detailed checks in hospitals or care homes
Braden Scale – Great for quick checks in hospitals or long-term care
Norton Scale – Simple and often used in community care
PURPOSE-T – Newer tool used in NHS trusts; person-centred and modern

✅ Check your workplace’s policy to make sure you’re using the correct tool.

2. Understand What the Tool Measures

Learn what each tool looks at, such as:

Mobility
Nutrition
Skin condition
Moisture or continence

Know how the tool scores risk:

Waterlow: Higher score = higher risk (10+ = at risk)
Braden: Lower score = higher risk (12 or less = high risk)
Norton: Lower score = higher risk (14 or less = at risk)
PURPOSE-T: Uses a step-by-step pathway to decide risk level

Use training guides (like NICE NG215) to help understand each part.

3. Do the First Assessment Early

Do the first check:

Within 6 hours of admission (as NICE recommends)
Or when a patient’s condition changes

Get good information by:

Looking at the patient (e.g. checking their skin and movement)
Checking medical records (e.g. diet, health issues)
Talking to the patient or family about important things (like continence).

4. Score Accurately

Follow each tool’s scoring instructions closely
Don’t guess—use what you see now, not old notes
Double-check scores for high-risk patients
If you’re not sure, ask a colleague or supervisor.

5. Record Everything Clearly

Write the results in the patient’s record (paper or electronic):

Name of the tool (e.g. Braden)
Score and what it means (e.g. Braden 10 = high risk)
Date, time, and your name
What you will do next (e.g. “Start SSKIN bundle”)

Good records help other staff and support safe, clear care.

6. Make a Personal Care Plan

Use the risk level to plan care:

Low risk – Basic care like checking skin and giving advice
High risk – More support, like pressure-relieving mattresses, help with moving, and better nutrition

Use plans like the SSKIN bundle:

Surface – Use the right cushion or mattress
Skin – Check skin often
Keep moving – Reposition often
Incontinence – Keep skin clean and dry
Nutrition – Give help with food and fluids

Work with the whole care team (e.g. dietitian, physiotherapist).

7. Reassess Often

Check again regularly (e.g. daily in hospital, weekly in care homes)
Re-check if the patient’s health changes (e.g. after surgery or weight loss)
Update the care plan as needed.

8. Involve the Patient and Family

Explain the risk and what you’re doing to help
Ask them to join in—like reporting pain or helping with repositioning
Teach them about how to prevent pressure ulcers at home

9. Use Training and Support

Join training sessions about pressure ulcer tools
Check NHS or NICE websites for updates
Ask wound care or tissue viability nurses for help with difficult cases.

10. Monitor and Improve

Review how well risk tools and care plans are being used.
Join audits (like the NHS Safety Thermometer).
Use feedback to improve and lower pressure ulcer cases.

Tips for Success

✅ Be Consistent – Use the same tool across your team
👥 Work as a Team – Share results during handovers
📚 Stay Updated – Tools like PURPOSE-T change with new research
⏱️ Don’t Rush – Take your time to assess correctly.

Things to Keep in Mind

These tools are helpful, but not perfect.

No single tool works 100% of the time for every patient.
Some tools are better for certain types of patients or care settings.
Risk factors like medicines or mental health issues may not be covered by the tool and need extra attention.
Don’t rely too much on the score alone—this can lead to poor decisions or wasted resources.

What the NICE Guidelines Say

The National Institute for Health and Care Excellence (NICE) says that all adults admitted to hospital or care homes should have a pressure ulcer risk assessment.

They don’t tell you which tool to use, but the assessment should include:

How well the person can move
The condition of their skin
Blood flow and oxygen to the skin
Skin moisture (e.g. from incontinence)
How well they can feel pain or pressure
Their nutrition
If they’ve had pressure ulcers before
Their mental awareness
Any sudden illness

Conclusion

Pressure ulcer risk tools are very important for keeping people safe and preventing harm. When used with good clinical judgement and a full care plan, they greatly reduce the risk of pressure ulcers.

Newer tools like PURPOSE-T show that pressure ulcer care is improving, with more focus on the whole person.

Healthcare teams should:

Use clear protocols
Keep learning through training
Understand not just how to fill in the tool, but how to think about the patient as a whole

The main goal is always the same: to protect patients from harm that can be prevented.

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