Risk assessment instruments for pressure ulcer in adults in critical situation: a scoping review

Ricardo Jorge de Barros Romeira Picoito, Sara Maria May Pereira da Cruz Lapuente, Alexandra Catarina Parreira Ramos, Isabel Cristina Mascarenhas Rabiais, Sérgio Joaquim Deodato, Elisabete Maria Garcia Teles Nunes

Research output: Contribution to journalReview articlepeer-review



OBJECTIVE: to map the instruments for risk assessment of pressure ulcers in adults in critical situation in intensive care units; identify performance indicators of the instrument, and the appreciation of users regarding the instruments' use/limitations. METHOD: a scoping review. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews in the writing of the study. We carried out the searches in the EBSCOhost search tool for 8 databases, resulting in 1846 studies, of which 22 studies compose the sample. RESULTS: we identified two big instrument groups: generalist [Braden, Braden (ALB), Emina, Norton-MI, RAPS, and Waterlow]; and specific (CALCULATE, Cubbin & Jackson, EVARUCI, RAPS-ICU, Song & Choi, Suriaidi and Sanada, and COMHON index). Regarding the predictive value, EVARUCI and CALCULATE presented better results for performance indicators. Concerning appreciation/limitations indicated by users, we highlight the CALCULATE scale, followed by EVARUCI and RAPS-ICU, although they still need future adjustments. CONCLUSION: the mapping of the literature showed that the evidence is sufficient to indicate one or more instruments for the risk assessment of pressure ulcers for adults in critical situation in intensive care units. (1) The risk assessment instrument must be applied to the patient's specificities. (2) The instruments are divided into two groups: generalist and specific. (3) The EVARUCI and CALCULATE instruments presented better results. (4) The EVARACI presented better results in terms of performance indicators. (5) The CALCULATE highlights itself for being recent scale, appropriate, simple, and easy to use.

Original languageEnglish
Article numbere3983
Number of pages15
JournalRevista Latino-Americana de Enfermagem
Publication statusPublished - 6 Oct 2023


  • Risk assessment
  • Pressure ulcer
  • Intensive care units
  • Predictive value of tests
  • Sensibility and specificity
  • Adult


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