How To
2
try this
HOURS
Continuing Education
By Nancy A. Stotts, EdD, RN, FAAN, and Lena Gunningberg, PhD, RN
Predicting
Pressure Ulcer Risk
Dana EchoHawk
Using the Braden scale with hospitalized older adults:
the evidence supports it.
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http://www.nursingcenter.com
read it watch it try it
Web Video
Overview: Pressure ulcers are a serious concern in caring for older adults in all settings. In
addition to being painful and expensive to
treat, they can significantly compromise a
patient’s mental, emotional, and social wellbeing. The Braden Scale for Predicting Pressure
Sore Risk assesses a patient’s risk of developing
these ulcers so that those judged to be at risk
can receive preventive care. The scale consists
of six subscales and can be completed in just
one minute. (This screening tool is included in
a series, Try This: Best Practices in Nursing
Care to Older Adults, from the Hartford Institute for Geriatric Nursing at New York University’s College of Nursing.) For a free online
video demonstrating the use of this tool, go to
http://links.lww.com/A106.
E
ighty-six-year-old Fred Adams was hit by
a car as he crossed the intersection near
his house. (This case is a composite based
on the authors’ experiences.) Transported
by ambulance to the ED of a nearby hospital, he arrives with a blood pressure reading of
134/84 mmHg; heart rate, 92 beats per minute; respirations, 20 breaths per minute; and temperature,
36.2°C (97.2°F). He is alert and oriented and able to
describe what happened: a woman driving a small car
failed to see him as she made a left turn into the intersection, knocking him over and rolling him onto the
sidewalk. Mr. Adams reports that he has hypertension, which is controlled with hydrochlorothiazide
(HydroDIURIL and others) 12.5 mg per day. On
examination his cranial nerve function is within normal limits. Motion and sensation are present in all
extremities, although motion in his left leg is limited
and painful because of an injury to his left hip. He
does not want to be moved or have his hip or leg
touched. Admission data indicate that he lives alone,
drives his own car, and manages his household independently. After an X-ray confirms a fracture of the
left hip in the intertrochanteric region, Mr. Adams is
transferred immediately to surgery for internal fixation of the joint. After postoperative admission to the
[email protected]
Watch a video demonstrating the use and
interpretation of the Braden scale at http://
links.lww.com/A106.
A Closer Look
Get more information about pressure ulcer risk
and assessment in older adults.
Try This: Predicting Pressure
Ulcer Risk
This is the Try This tool in its original form.
See page 45.
Online Only
Unique online material is available for this article. Direct URL citations appear in the printed
text; simply type the URL into any Web browser.
orthopedic unit, he is evaluated with the Braden Scale
for Predicting Pressure Sore Risk.
WHY USE THE BRADEN SCALE?
The Braden Scale for Predicting Pressure Sore Risk
was developed to help nurses determine patients’
risk of developing pressure ulcers. The scale, which
takes less than a minute to complete, has been used
with patients of all ages and in all settings and has
been found to be more accurate than other scales
(including the Norton and the Waterlow scales) or
clinical judgment.1 While its use alone does not prevent pressure ulcers, its findings are the sentinel that
calls nurses to employ preventive strategies. For information on preventing pressure ulcers and using guidelines, go to http://links.lww.com/A183.
It was developed in the 1980s by nurses Barbara
Braden and Nancy Bergstrom, who established that
the “critical determinants” of pressure ulcer development are2:
1. the intensity and duration of pressure
2. the ability of the skin and supporting tissues to
tolerate pressure
They also described the factors influencing these
two determinants. Mobility, activity, and sensory
perception contribute to the intensity and duration
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How To
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Watch It!
o to http//links.lww.com/A106 to watch a nurse use the
Braden scale in an actual patient and discuss how to administer and interpret it quickly. Then watch the health care team
plan preventive strategies.
View this video in its entirety and then apply for CE credit at
www.nursingcenter.com/AJNolderadults; click on the How to Try
This series link. All videos are free and in a downloadable format
(not streaming video) that requires Windows Media Player.
G
of pressure. Tissue tolerance is influenced by both
extrinsic factors (moisture, friction, and shear) and
intrinsic factors (nutrition, age, and arterial pressure).
Six of these factors became the subscales of the Braden
scale. (See Why Assess Pressure Ulcer Risk? page 43.)
• sensory perception
• activity
• mobility
• skin moisture
• nutritional intake
• friction and shear
ADMINISTERING THE BRADEN SCALE
The patient is evaluated on each of the six subscales,
with the scoring based on the descriptions provided in
the tool (see Try This, page 45). The nurse uses physical assessment and interviewing to elicit the data to
complete the Braden scale. Scores for the levels of risk
within each subscale range from 1 to 4, with the
exception of friction and shear, which is scored from
1 to 3. Each subscale includes a title; within the subscale, each level has a key concept description and
one or two phrases or sentences describing its qualifying attributes. For example, in the subscale “activity,” the lowest score—1—is given when a patient is
“bedfast,” followed by a 2 for one who is “chairfast,”
a 3 for a patient who “walks occasionally,” and a 4
for one who “walks frequently.” Item descriptors
determine the patient’s score. For example, in order to
score a 4 in the activity subscale, the patient must
walk “outside [the] room at least twice a day and
inside [the] room at least once every two hours during waking hours,” according to the scale. It’s important not to alter the scale by adding or deleting items
or by modifying existing definitions; any such change
will result in inaccuracy.12 The final score—obtained
by totaling the scores from the six subscales—ranges
from 6 to 23. To view the segment of the online video
showing a nurse completing the Braden scale, go to
http://links.lww.com/A107.
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The Wound, Ostomy, and Continence Nurses
Society (WOCN) recommends that all patients in
acute, long-term, and home care be assessed for risk
of pressure ulcers at the time of admission.
Mr. Adams. Upon entering Mr. Adams’s room, his
nurse introduces herself and begins the assessment.
“I’m Frances Cornell, and I’m the nurse caring for
you today,” she says. “I need to ask you some questions, some of which may seem silly. But can you
tell me who you are, where you are, and what the
date is?”
Mr. Adams’s answers confirm that he is alert and
oriented to time, place, and person. Next she asks,
“Are you having pain? How would you describe it
on a scale of 0 to 10, where 0 is no pain and 10 is
the worst pain imaginable?” Mr. Adams says that
his pain is an 8. Taking both of these answers into
account, she records a score of 4, meaning “no
impairment,” on the sensory perception subscale.
This subscale measures the “ability to respond
meaningfully to pressure-related discomfort” by
looking at both the patient’s perception of pain and
her or his level of consciousness.
Mr. Adams is perspiring heavily, probably because
of his pain. The nurse finds no evidence of incontinence or wound drainage, so she assigns a score of
3, “occasionally moist,” on the moisture subscale.
Ms. Cornell checks the incision and makes sure
the hip-abduction pillow is securely in place. As she
settles him in, she notes that he is on bed rest today
and gives him a score of 1, “bedfast,” on the activity subscale. He can make slight changes in position, but as is to be expected with this type of injury,
he can’t change position independently. His mobility is “very limited,” and he receives a 2 on this subscale. Because he requires assistance to move, he
also scores a 2, “potential problem,” on the friction
and shear subscale.
Ms. Cornell asks for specific information on his
nutritional status, noting that he reported in the ED
that he lives alone and does his own shopping and
cooking. “How would you describe your eating yesterday?” she asks. “Coffee and a banana for breakfast,” he answers. “I wasn’t very hungry at noon so
I had cold cereal with milk. For dinner, I had a can
of mushroom soup. I thought about having toast
with it but I just wasn’t that hungry. Later, I had
two chocolate chip cookies for a snack.”
Although Mr. Adams’s body mass index (BMI) is
in the normal range, his intake the previous day
was insufficient. Since being hospitalized, he has
taken limited liquids, has received intravenous crystalloid fluids, and has had no nutrition since his
surgery. The nurse anticipates that it will take a few
http://www.nursingcenter.com
Why Assess Pressure Ulcer Risk?
The importance of avoiding pressure ulcers.
ressure ulcers are a significant problem in hospitalized older adults. In the United States, Canada, and
parts of Europe, prevalence ranges from 14% to 25%
and incidence from 7% to 9%.3-5 One study found a
slightly lower incidence (6.2%) when older adults were
assessed for risk early in the hospital stay.6
Research shows that pressure ulcers and their treatment negatively affect every dimension of a patient’s life:
emotional, mental, physical, and social.7 Patients in one
study reported experiencing “endless pain,” and those in
another said that nursing staff didn’t acknowledge or treat
their discomfort and pain (although they received many
pressure ulcer–related interventions).7, 8 Even usual nursing
care, such as turning, has been found to be painful for
patients with pressure ulcers.8, 9
P
days for him to reach adequate intake. Thus, he
receives a score of 1, “very poor,” on the nutrition
subscale.
Challenges that may arise. Because the sensory
perception subscale includes two areas for assessment—the patient’s level of consciousness and his
perception of pain (see the scale on page 46)—the
lower of the two scores should be assigned. For
example, a patient who has had a stroke and is alert
(a 4 on the subscale) but has sensory deficits in a single limb because of disease (a 3) should receive a
score of 3 for the subscale.
It can be challenging to complete an accurate
evaluation for the nutrition subscale. This subscale
scores “usual” intake and is applicable to eating as
well as to feeding methods such as ivs, total parenteral nutrition, or tube feeding. Assessment of
oral intake requires knowledge of the patient’s eating patterns, so data must be gathered over several
days. If a patient is nonresponsive upon admission
and family or friends cannot report on intake, nutritional status can be evaluated using BMI and serum
albumin level; the assessment will also take into
account current plans for the patient’s nutrition (for
example, if the patient has an injury that will prohibit intake or she or he is to take nothing by mouth
for several days for tests or treatments). Clinical
judgment is used to assign a score. The rule of
thumb is to “do no harm,” so if the data are borderline, assign a lower risk score.
Similarly, because it often takes several days for
tube feeding target goals to be reached, the patient
may be underfed. In this case, a score of 2 should
be assigned because the patient is receiving “less
than [the] optimum amount of liquid diet or tube
feeding.”
[email protected]
Pressure ulcers are also expensive to treat. Beckrich
and Aronovich estimated in 1999 that the annual cost of
hospital-acquired pressure ulcers was $2.2 billion to
$3.6 billion.10 Costs vary by the severity of the ulcer, its
location, and the goals of treatment, but they may include
the nursing time required to treat ulcers and turn
and position patients; pressure-relieving devices (mattresses, cushions); dressings, antibiotics, and surgical
treatment (such as debridement); and physicians’ fees.
Other expenses include hospital and nursing home room
fees and additional hospitalization for people who
develop ulcers while hospitalized for another condition.11
To view the segment of the online video discussing
Braden scale scores, go to http://links.lww.com/
A109.
SCORING AND INTERPRETING RESULTS
Levels of risk have been defined as the following
categories of scores13:
• 19 to 23: not at risk
• 15 to 18: at risk
• 13 to 14: at moderate risk
• 10 to 12: at high risk
• 6 to 9: at very high risk
Lower scores suggest higher risk and require
more aggressive preventive efforts.12 Care for those
with a score of 19 or higher can proceed without
special attention to pressure ulcer risk. The Braden
scale’s characterization of pressure ulcer risk as a
numerical value makes a change in status easy to
identify and act upon. To view the segment of the
online video discussing Braden scale scores, go to
http://links.lww.com/A109.
Mr. Adams’s Braden scale score upon admission
was 13 out of 23, indicating a moderate risk of pressure ulcers. Of foremost concern were his results on
the activity, mobility, and friction and shear subscales;
his scores on the nutrition and moisture subscales also
indicated possible risk.
Following the hospital’s protocol, a nurse evaluates Mr. Adams’s skin at all major pressure points:
heels, ankles, sacrum, ischial tuberosities, the
trochanteric area, elbows, shoulder blades, spine,
and the back of the head. She documents the status
of his surgical incision. His skin is intact and there
are no areas of redness over bony prominences.
Special care is taken to assess his heels and sacrum,
which are the most common sites of pressure
ulcers.14 Mr. Adams is particularly susceptible to
damage in these areas because he will be spending
considerable time in the supine position, and he will
be using the heel of his good leg to help him turn
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How To
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and use the bedpan. Both of his heels are suspended
above the bed with pillows under the calves. The
hospital recently replaced all of its mattresses with
pressure-relieving mattresses. In hospitals that have
older mattresses, a mattress overlay or a low air
loss mattress can be used, although some data indicate positive outcomes for hip fracture patients for
whom a pressure reducing overlay or mattress is
not routinely used in postoperative care.15
The nurse writes a plan of care that incorporates
pressure ulcer prevention. To make sure Mr. Adams
is repositioned regularly, two cues are used in the
room. A navy blue sticker is attached to the white
board at the foot of his bed (where daily activities are
listed), which reminds the staff to keep the head of the
bed at 30° or lower, except at mealtimes. Also, a
clock-shaped repositioning schedule is posted on the
board to serve as a reminder of when and how Mr.
Adams should be repositioned. In addition, every two
hours the overhead paging system plays a four-note
jingle to remind the staff that it’s time to turn patients.
The nurse also asks the dietitian to perform a
routine nutritional evaluation to ensure that Mr.
Adams is taking in enough calories, protein, and
fluids. His blood will be drawn for laboratory
analysis of total protein, albumin, and prealbumin
levels, which will help determine whether nutritional supplementation is needed.
Daily Braden scale scoring and skin reassessment
will indicate whether Mr. Adams’s plan of care
should be modified.
Reassessment schedules are set by the health care
facility, according to the nature of its population.
Reassessment is recommended when a patient’s condition changes, as well as at regular intervals.16-18 In
home care, reassessment at each visit is recommended.17 There is some disagreement, however, on
how often reassessment should be done in hospitals
and long-term care facilities. In hospitals, the Institute
for Healthcare Improvement recommends daily reassessment,16 while the WOCN recommends reassessment every 48 hours.17 For patients in long-term
care, the WOCN recommends weekly assessment for
four weeks and then quarterly,17 while the American
Medical Directors Association recommends that
high-risk patients be reassessed quarterly.18
OTHER CONSIDERATIONS
Differences between nurses’ or patients’ cultures
are unlikely to affect the accuracy of the Braden
scale since there is little in the scale that asks for
interpretation of meaning or symbols. On the other
hand, a patient’s skin tone can affect a nurse’s ability
to detect pressure ulcers. Risk assessment with the
Braden scale has been examined in different racial
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groups. For example, Bergstrom and Braden compared cutoff scores (the number at or below which
the patient is considered at risk) for black and white
patients and found that the cutoff score of 18 “best
predicts risk for both groups.”19 Lyder and colleagues explored pressure ulcer prediction with the
Braden scale in black and Hispanic patients and
found that a cutoff score of 18 was valid for predicting pressure ulcer risk in black patients ages 75
years and older.20
Translations of the Braden scale are available in
Chinese, Japanese, Dutch, French, German, Italian,
Portuguese, and Swedish.5, 21, 22
COMMUNICATING THE RESULTS
Because patients are a part of the health care team,
they should be apprised of their pressure ulcer risk
status. It’s important also to give them an overview
and explanation of the prevention plan. With the
patient’s approval, family members may also be
apprised of this information and enlisted to help
with prevention efforts.
The patient’s permanent record is used to communicate pressure ulcer risk to other health care
professionals; report at change of shift is also important. Various “bedside” strategies used to alert staff
to a patient’s increased pressure ulcer risk include
putting a sticker denoting risk on the white board at
the foot of the patient’s bed and posting a turning
schedule near the bed (for sample schedules see
www.bradenscale.com/turning.htm). The video segment demonstrating how to communicate the results
of the Braden scale assessment in preparation for discharge is available at http://links.lww.com/A110.
Mr. Adams. Ms. Cornell tells Mr. Adams that her
assessment suggests he’s at risk for pressure ulcers
and explains why that’s an important concern. She
discusses the hazards of being immobile with Mr.
Adams and his younger sister, Jane Diehl, who is
visiting him in his hospital room. She explains that
Mr. Adams is at risk for pressure ulcers because of
his fracture and its treatment, and she describes the
preventive care that has been implemented. She
asks them to help with turning and positioning and
fluid intake when possible. “Mr. Adams, you can
help the nurse position you when you’re turned
every two hours. Also, if you find that two hours
have gone by and you haven’t been turned, or if
you need help between the scheduled turns, please
let us know. Ms. Diehl, if you come in and see that
it’s time for him to be turned, don’t hesitate to ask
one of the staff to reposition him. Mr. Adams, we
also want you to drink a lot of liquids to stay well
hydrated, so we’ll try to leave your water pitcher
within your reach. If we forget, please remind us.
http://www.nursingcenter.com
from
Issue Number 5, Revised 2007
Series Editor: Marie Boltz, PhD, APRN, BC, GNP
Managing Editor: Sherry A. Greenberg, MSN, APRN, BC, GNP
New York University College of Nursing
Predicting Pressure Ulcer Risk
By: Elizabeth A. Ayello, PhD, APRN, BC, CWOCN, FAPWCA, FAAN
Excelsior College School of Nursing
WHY: Pressure ulcers (PUs) occur frequently in hospitalized, community-dwelling and nursing home older adults, and are serious
problems that can lead to sepsis or death. Prevalence of PUs ranges from 10-17% in acute care, 0-29% in home care, and 2.3-28%in
institutional long-term care (LTC); incidence ranges from 0.4-38% in acute care, 0-17% in home care, and 2.2-23.9% in institutional LTC.
A key to prevention is early detection of at risk patients with a valid and reliable PU risk assessment instrument and timely interventions.
BEST TOOL: The Braden Scale for Predicting Pressure Sore Risk is among the most widely used tools for predicting the development
of PUs. Assessing risk in six areas (sensory perception, skin moisture, activity, mobility, nutrition and friction/shear), the Braden Scale
assigns an item score ranging from one (highly impaired) to three/four (no impairment). Summing risk items yields a total overall risk,
ranging from 6-23. If a patient has major risk factors such as fever, diastolic pressure below 60, hemodynamic instability, advanced age,
then move them to the next level of risk. Scores 15 to 18 indicate at risk, 13 to 14 indicate moderate risk, 10 to 12 indicate high risk,
≤ 9 indicate very high risk. In addition to assessing total overall risk, basing prevention protocols on low sub-scores are required by
Centers for Medicare and Medicaid Centers in the revised Tag F 314 for long term care. Targeting specific prevention interventions that
address low risk sub-scores can offer effective resource use.
TARGET POPULATION: The Braden Scale is commonly used with medically and cognitively impaired older adults. It has been
used extensively in acute, home, and institutional LTC settings. New PUs are more common in the first two weeks of admission to a
hospital or LTC. Recommendations for assessment are on admission or when the patient’s condition changes (including cognition or
functional ability) and at the following intervals: acute care-every 48 hours; critical care-every 24 hours; home care-every RN visit;
institutional LTC-weekly first 4 weeks after admission, monthly to quarterly.
VALIDITY AND RELIABILITY: The ability of the Braden Scale to predict the development of PUs (predictive validity) has been tested
extensively. Inter-rater reliability between .83 and .99 is reported. The tool has been shown to be equally reliable with Black and White
patients. Sensitivity ranges from 83-100% and specificity 64-90% depending on the cut-off score used for predicting PU risk. A cut-off
score of 18 should be used for identifying Black and White patients at risk for pressure ulcers.
STRENGTHS AND LIMITATIONS: When utilized correctly and consistently, the Braden Scale will help identify the associated risk
for PU so that appropriate preventive interventions can be implemented. Although the Braden Scale has been used primarily with
White older adults, research addressing Braden Scale efficacy in Black and Latino populations suggests that a cut-off score of 18 or
less prevents under-prediction of PU risk in these populations.
MORE ON THE TOPIC:
Best practice information on care of older adults: www.ConsultGeriRN.org.
Ayello, E.A., & Braden, B. (2002). How and why to do pressure ulcer risk assessment. Advances in Skin and Wound Care, 15(3), 125-132.
Baranoski, S., & Ayello, E.A. (2004). Wound care essentials: Practice principles. Springhouse PA: Lippincott Williams & Wilkins.
Bergstrom, N., & Braden, B.J. (2002). Predictive validity of the Braden Scale among Black and White subjects. Nursing Research, 51(6), 398-403.
Bergstrom, N., Braden, B.J., Laguzza, A., & Holman, V. (1987). The Braden Scale for predicting pressure sore risk. Nursing Research, 36(4), 205-210.
Braden Scale. http://www.bradenscale.com. Last accessed June 27, 2007.
Center for Medicare and Medicaid Services (CMS) Tag F 314 Pressure Ulcers Guidance for Surveyors in Long Term Care. Last accessed August 9, 2006 from
http://new.cms.hhs.gov/manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
Cuddigan, J., Ayello, E.A., & Sussman, C. (2001). Pressure ulcers in America: Prevalence, incidence & indications for the future. Reston VA: NPUAP
(National Pressure Ulcer Advisory Panel).
Lyder, C.H., Yu, C., Stevenson, D., Mangat, R., Empleo-Frazier, O., Emrling, J., & McKay, J. (1998). Validating the Braden Scale for the prediction of
pressure ulcer risk in Blacks and Latino/Hispanic elders: A pilot study. Ostomy/Wound Management, 44(3A), Suppl: 42S-50S.
U.S. Department of Health and Human Services, Agency for Health Care Research and Quality. (1992). Pressure ulcers in adults: Prediction and prevention
(AHCPR Publication No. 92-0047). Rockville, MD: Author.
Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for not-for-profit educational purposes only, provided that
The Hartford Institute for Geriatric Nursing, College of Nursing, New York University is cited as the source. This material may be downloaded and/or distributed in electronic
format, including PDA format. Available on the internet at www.hartfordign.org and/or www.ConsultGeriRN.org. E-mail notification of usage to: [email protected].
✁
[email protected]
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EMAIL : [email protected]
HARTFORD INSTITUTE WEBSITE : www.hartfordign.org
CONSULTGERIRN WEBSITE : www.ConsultGeriRN.org
http://www.nursingcenter.com
Online Resources
And Ms. Diehl, feel free to help place it within his
reach and to bring him some special liquids that he
might like.” They also discuss the importance of
daily skin evaluation and reevaluation with the
Braden scale.
Mr. Adams’s postoperative course is uneventful.
The pressure ulcer prevention plan is successful, with
the staff consistently implementing the plan and
reassessing him with the Braden scale daily. During his
seven-day hospital stay, his situation improves and he
is mobilized, his pain is controlled, and his nutritional
intake improves; ultimately, he is discharged with his
skin intact. He follows his hospital stay with 20 days
at a nearby skilled nursing facility, where additional
physical therapy enables him to resume his independent life. To view the segment of the online video on use
of the tool as a continuous quality improvement intervention, go to http://links.lww.com/A108.
CONSIDER THIS
The widely used Braden Scale for Predicting Pressure
Sore Risk is regarded as the best tool for identifying
pressure ulcer risk and indicating the need for preventive measures. Here are some additional considerations.
What evidence supports relying on the Braden
scale to identify patients at risk for pressure ulcer?
The Braden scale has been widely studied to determine whether it predicts pressure ulcer risk. Early
studies established its value.21, 23, 24 Although rigorously
conducted, these studies were done when pressure
ulcer prevention was not a standard part of nursing
care. As pressure ulcer prevention has become routine
in hospital care, study results have changed. Today
when a prevalence study is conducted, it measures the
number of people who have pressure ulcers with some
pressure ulcer prevention having been undertaken.
Thus, the ability of the Braden scale to accurately predict who will develop pressure ulcers cannot be
assessed as purely as before. Nevertheless, the available research indicates that it does a good job of predicting ulcer development and can be relied upon in
clinical settings. (For more information on interpreting psychometric aspects of tools, see “Define Your
Terms,” October.)
• Reliability. The Braden scale has high (r = 0.99)
interrater reliability among RNs on medical–
surgical and critical care step-down units.2
• Validity. The Braden scale has demonstrated strong
predictive validity, meaning that it effectively predicts the development of pressure ulcers. For
example, in one study that used a cutoff score of
16 in 60 critical care patients, researchers found
that the scale’s positive predictive validity (correctly predicting that a pressure ulcer would
occur) was 61% and its negative predictive [email protected]
or more information on the Braden Scale for Predicting
Pressure Sore Risk and additional resources, including a
video for training staff on its use and competency tests, go to
www.bradenscale.com. The Braden Scale is protected by copyright. Permission can be obtained, usually free of charge, for
patient settings at this web site. For other geriatric assessment
tools and best practices, go to www.hartfordign.org, the Web
site of the John A. Hartford Foundation–funded Hartford Institute
for Geriatric Nursing at New York University College of
Nursing. The institute focuses on improving the quality of care
provided to older adults by promoting excellence in geriatric
nursing practice, education, research, and policy.
Download the original Try This document on the Braden Scale
for Predicting Pressure Sore Risk by going to www.hartfordign.
org/publications/trythis/issue05.pdf.
For more information on best practices in the care of older
adults go to www.ConsultGeriRN.org. The site lists many related
resources and offers continuing education opportunities.
Go to www.nursingcenter.com/AJNolderadults and click on the
How to Try This link to access all articles and videos in this series.
F
ity (correctly predicting that a pressure ulcer would
not occur) was 86%.23
❍ Sensitivity. In a systematic review of 33 studies,
researchers concluded that the Braden scale’s
sensitivity—its ability to identify those at risk
for pressure ulcers—has been extensively validated and is reasonably good (57.1%).1
❍ Specificity. The same review found that the
Braden scale has reasonably good specificity
(67.5%), indicating that nurses can be fairly confident that the scale will accurately determine
that someone with a high score is not at risk for
developing a pressure ulcer.1
For a more complete discussion of the studies on
the psychometric properties of the Braden scale, go
▼
to http://links.lww.com/A182.
Nancy A. Stotts is a professor at the School of Nursing, University
of California, San Francisco, where she is associate director of
the John A. Hartford Center of Geriatric Nursing Excellence.
Lena Gunningberg is an assistant professor and leader of the
Department of Nursing Research and Development, Surgery
Division, at Uppsala University Hospital, Sweden. Contact author:
Nancy Stotts, [email protected]. The authors have no
significant ties, financial or otherwise, to any company that might
have an interest in the publication of this educational activity.
How to Try This is a three-year project funded by a grant from
the John A. Hartford Foundation to the Hartford Institute for
Geriatric Nursing at New York University’s College of Nursing in
collaboration with AJN. This initiative promotes the Hartford
Institute’s geriatric assessment tools, Try This: Best Practices in
Nursing Care to Older Adults: www.hartfordign.org/trythis. The
series will include articles and corresponding videos, all of which
will be available for free online at www.nursingcenter.com/
AJNolderadults. Stotts and Sherry A. Greenberg, MSN, APRN,BC,
GNP ([email protected]), are coeditors of the print series.
The articles and videos are to be used for educational purposes only.
Routine use of a Try This tool may require formal review
and approval by your employer.
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try this
REFERENCES
1. Pancorbo-Hidalgo PL, et al. Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs 2006;
54(1):94-110.
2. Bergstrom N, et al. The Braden Scale for Predicting Pressure
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3. Whittington KT, Briones R. National Prevalence and Incidence
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4. Woodbury MG, Houghton PE. Prevalence of pressure ulcers
in Canadian healthcare settings. Ostomy Wound Manage
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5. Vanderwee K, et al. Pressure ulcer prevalence in Europe: a
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6. Baumgarten M, et al. Pressure ulcers among elderly patients
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7. Spilsbury K, et al. Pressure ulcers and their treatment and
effects on quality of life: hospital inpatient perspectives.
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8. Hopkins A, et al. Patient stories of living with a pressure
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9. Rastinehad D. Pressure ulcer pain. J Wound Ostomy
Continence Nurs 2006;33(3):252-7.
10. Beckrich K, Aronovitch SA. Hospital-acquired pressure
ulcers: a comparison of costs in medical vs. surgical
patients. Nurs Econ 1999;17(5):263-71.
11. Javitz HS, et al. Major costs associated with pressure sores.
J Wound Care 1998;7(6):286-90.
12. Ayello EA, Braden B. How and why to do pressure ulcer
risk assessment. Adv Skin Wound Care 2002;15(3):125-31.
13. Braden BJ, Maklebust J. Preventing pressure ulcers with the
Braden scale: an update on this easy-to-use tool that
assesses a patient’s risk. Am J Nurs 2005;105(6):70-2.
14. Cuddigan JG, et al. Pressure ulcers in America: prevalence,
incidence, and implications for the future. Reston, VA:
National Pressure Ulcer Advisory Panel; 2001.
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with a hip fracture after implementation of a perioperative
evidence-based clinical pathway. Qual Saf Health Care 2006;
15(5):375-9.
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http://
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for the prevention and management of pressure ulcers.
Mount Laurel, NJ; 2002. Report 000-2002.
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[Clinical Practice Guideline]. Columbia, MD; 1996. CPG2.
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Scale among Black and White subjects. Nurs Res
2002;51(6):
398-403.
20. Lyder CH, et al. Validating the Braden Scale for the prediction of pressure ulcer risk in blacks and Latino/Hispanic elders: a pilot study. Ostomy Wound Manage 1998;44(3A
Suppl):
42S-49S.
21. Bergstrom N, et al. Using a research-based assessment scale
in clinical practice. Nurs Clin North Am 1995;30(3):53951.
22. Torra i Bou JE. [Evaluating the risks of pressure ulcers. The
Braden scale]. Rev Enferm 1997;20(224):22-30.
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22(2):417-28.
48
AJN ▼ November 2007
▼
Vol. 107, No. 11
2
HOURS
Continuing Education
EARN CE CREDIT ONLINE
Go to www.nursingcenter.com/CE/ajn and receive a certificate within minutes.
GENERAL PURPOSES: To present registered professional
nurses with comprehensive information on pressure ulcers,
highlighting the use of the Braden Scale for Predicting
Pressure Sore Risk.
LEARNING OBJECTIVES: After reading this article and taking
the test on the next page, you will be able to
• present the background information essential for understanding the need for and the development and use of
the Braden scale.
• plan the essential steps for determining a patient’s
Braden score and intervening accordingly.
• outline the information relevant to the use of the Braden
scale and its subscales.
TEST INSTRUCTIONS
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nursingcenter.com/CE/ajn.
To use the form provided in this issue,
• record your answers in the test answer section of the CE
enrollment form between pages 48 and 49. Each question has only one correct answer. You may make copies
of the form.
• complete the registration information and course evaluation. Mail the completed enrollment form and registration
fee of $19.95 to Lippincott Williams and Wilkins CE
Group, 2710 Yorktowne Blvd., Brick, NJ 08723, by
November 30, 2009. You will receive your certificate in
four to six weeks. For faster service, include a fax number
and we will fax your certificate within two business days
of receiving your enrollment form. You will receive your CE
certificate of earned contact hours and an answer key to
review your results. There is no minimum passing grade.
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TEST CODE: AJNTT03
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