Risk Assessment
From screening to full risk assessment in Pressure Injury Prevention
Effective pressure injury prevention depends on identifying the right patients at the right time and targeting preventive measures accordingly. The International Guideline on the Prevention and Treatment of Pressure Injuries recommends a two-step approach to risk assessment, combining early screening with a comprehensive risk assessment for those identified as potentially at risk.
Why risk assessment matters
Risk assessment is a clinical reasoning process aimed at identifying individuals who are likely to develop pressure injuries and at detecting the specific risk factors that require intervention. Because patient populations vary widely in their baseline risk, a uniform approach to assessment may lead to unnecessary use of resources in low-risk individuals or missed prevention opportunities in others.
Step 1: Risk screening
Risk screening is performed in all newly admitted individuals, preferably within 2 hours after admission. The purpose is to rule out pressure injury risk in those with a low likelihood of developing a pressure injury. Screening focuses on easily observable and highly predictive risk indicators, such as limited mobility or activity, a high risk of friction or shear, or the presence of an existing stage 1 pressure injury.
In care settings where most individuals are already known to be at high risks (such as intensive care units, geriatric wards, or palliative care settings) the screening step may be omitted and replaced by an immediate full risk assessment.
Step 2: Full risk assessment
A full risk assessment is carried out for individuals whose risk cannot be ruled out during screening, or for those in predefined high-risk populations. This step aims to confirm risk status and to identify individual and modifiable risk factors, including mobility and activity limitations, skin condition, perfusion and circulation, nutrition, moisture, sensory perception, comorbidities, and the impact of medical devices.
The outcome should not be limited to a simple “at risk/not at risk” decision but should result in a clear overview of risk factors that inform an individualized prevention plan. Risk assessment is most effective when conducted as an interprofessional process, drawing on the expertise of all relevant health care professionals.
Tools and clinical judgment
Standardized risk assessment tools can support assessment but should not replace clinical judgment. Total risk scores alone are insufficient to guide prevention. Instead, clinicians should focus on identifying and addressing the specific risk factors relevant to each individual and care setting.
Key message
A two-step approach to pressure injury risk assessment supports efficient use of resources while improving patient safety. By combining early screening with targeted, comprehensive assessment, health care professionals can ensure that preventive measures are delivered to those who need them most—at the right time and in the right way.
How to assess pressure injury risk –
A two-step approach
- Screen all patients at admission
- Look for key red flags: limited mobility/activity, high friction or shear, existing pressure injury/injuries.
- Decide quickly
- If risk is ruled out: no further action, rescreen if condition changes.
- If risk cannot be ruled out: proceed to full risk assessment.
- Skip screening in high-risk settings
- Go directly to full risk assessment in populations with obvious high risk (e.g. ICU, geriatric or palliative care).
- Conduct a full risk assessment
- Identify individual and modifiable risk factors (mobility, skin status, nutrition, perfusion, sensory perception, moisture, medical devices).
- Document and act
- Use findings to create an individualized prevention plan.
- Reassess regularly and adjust interventions as needed.
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References
Haesler, E. (Ed.). (2026). Prevention and treatment of pressure ulcers/injuries: Clinical practice guideline (4th ed.). The International Guideline — International Guideline
Balzer, K., et al (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
Gefen A. (2024). The complex interplay between mechanical forces, tissue response and individual susceptibility to pressure ulcers. J Wound Care. 2024 Sep 2;33(9):620-628. doi: 10.12968/jowc.2024.0023. PMID: 39287029
Coleman, S. (2013) Patient risk factors for pressure ulcer development: systematic review. Int J Nurs Stud. 2013 Jul;50(7):974-1003. doi: 10.1016/j.ijnurstu.2012.11.019. Epub 2013 Feb 1. PMID: 23375662.
Kottner, J., et al (2024). Pressure ulcer risk assessment: Where will the journey take us? Int J Nurs Stud. 2024 Feb;150:104646. doi: 10.1016/j.ijnurstu.2023.104646. Epub 2023 Nov 22. PMID: 38096628.
