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The Risk of Risk Assessment: Pressure Ulcer Assessment and the Braden Scale
The accuracy of the Braden Scale is dependent on what the assessor perceives as the meaning of the parameters and how he or she understands the individuals’ risk. It requires that facilities encourage and expect the staff to exercise their nursing judgment in determining risk beyond the six components of the scale. Since no risk assessment can completely identify all of the factors that contribute to the development of wounds, LTC facilities should revisit their policies to provide support for nursing judgment to identify residents at risk for wounds beyond the limitations of formal risk assessment scales, including a validated tool such as the Braden Scale.
The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure ulcer as a “localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.”1 Individuals who are at a higher risk of developing pressure ulcers include those who are wheelchair- or bed-bound, those who have a disorder that affects blood flow (eg, diabetes, vascular disease), and those who are unable to move certain parts of their body due to a spine or brain injury or disease (eg, stroke). Pressure ulcers are most likely to appear on the sacrum, buttocks, and hips.
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There are six pressure ulcer stages defined by the NPUAP. Individuals with stage I pressure ulcers have intact skin with nonblanchable erythema of a localized area, normally over a bony prominence. Stage II pressure ulcers are characterized by partial thickness dermis loss; they present as shallow, open ulcers without slough or as intact or open/ruptured serum-filled or serosanginous-filled blisters. Residents with stage III pressure ulcers experience full thickness tissue loss; slough may be present, and, although subcutaneous fat may be visible in these ulcers, bone, tendon, and muscle are not exposed. Conversely, those with stage IV pressure ulcers have full thickness tissue loss with exposed bone, tendon, or muscle; in addition, slough or eschar may be present. The remaining two stages were added by the NPUAP in 2007. Unstageable ulcers are characterized by full thickness skin or tissue loss with unknown depth due to the fact that the ulcers are completely concealed by slough and/or eschar. Finally, individuals with suspected deep tissue injury experience a localized area of discolored intact skin or a blood-filled blister caused by underlying pressure- and/or shear-induced soft tissue damage.1
Case Vignette
An 80-year-old woman is admitted to the hospital for pneumonia. The patient has a history of advanced dementia, coronary artery disease, type 2 diabetes, osteoarthritis, and hypertension. A stage II pressure ulcer is found on her coccyx. The admitting nurse completes the admission assessment, including a Braden Scale to determine whether this patient is at high risk for pressure ulcers. The hospital policy dictates that for any patient with a Braden Scale score of 14 or below, pressure ulcer preventive measures, including a consultation with the wound care nurse, must be established. The admitting nurse determines that the patient has a total risk score of 17, which places her at mild risk for the development of wounds. The six parameters for the Braden Scale are scored as follows:
1. Sensory perception: 3 (slight impairment)
2. Moisture: 3 (occasionally moist)
3. Activity: 3 (walks occasionally)
4. Mobility: 3 (slight limitation)
5. Nutrition: 3 (adequate)
6. Friction/shear: 2 (potential problems)
Pressure ulcers are often difficult to treat, significantly impact an individual’s quality of life, and pose significant quality-of-care issues in long-term care (LTC) facilities, in terms of both citations by surveyors and civil litigation. Since the 1980s, several risk assessment tools, such as the Norton, Gosnell, and Braden Scales have been used to identify the individuals who may be the most likely to develop pressure ulcers in a variety of healthcare settings. Based on the aggregate score of the risk assessment, most facilities have policies that direct preventive interventions, including support surfaces, skin barriers, and nutritional interventions. The validity of the scale’s predictive power is markedly decreased in certain situations: if the scale has not been completely accurate, if the nurse fails to identify a patient who is truly at risk when some or all of the risk factors are present, or when additional risk factors should be considered. An understanding of the value and limitations of pressure ulcer risk scales in clinical practice is necessary to fully appreciate the needs of residents during the assessment process.
As stated above, a number of pressure ulcer risk assessment tools have been developed over the past 40 years2; however, attempts to capture the multiple clinical conditions of residents in a variety of settings have not been satisfactory. The Norton and Gosnell Scales have generally been replaced with the Braden Scale for Predicting Pressure Sore Risk, a clinically validated tool developed by Barbara J. Braden, PhD, RN, and Nancy Bergstrom, PhD, RN, that assesses the individual’s risk for developing pressure ulcers by examining six domains of functional capacity3: (1) sensory perception; (2) moisture; (3) activity; (4) mobility; (5) nutrition; and (6) friction/shear. The total of these six subscales is used to determine the relative risk of pressure ulceration in a given patient, with the lowest total scores indicating the highest risk for developing these lesions. Residents with a total score of 9 or less, for instance, are at very high risk; those with a score of 10 to 12 are at high risk; those with a score of 13 to 14 are at moderate risk; those with a score of 15 to 18 are at mild risk; and those with a score of 19 to 23 have no risk for developing pressure ulcers.
Braden and Maklebust4 found that the Braden Scale has a high degree of interrater reliability (defined as “a measure of the consistency of results when a tool is administered by different raters”) for registered nurses, but a low interrater reliability for licensed practical nurses (LPNs). LTC facilities that direct LPNs to complete residents’ admission assessments, which include calculating their Braden Scale scores, should be aware of this finding. The authors also noted that interrater reliability would likely improve for LPNs if appropriate education were provided. In a 2014 study, Choi and colleagues5 reported that nurses may inconsistently interpret the Braden Scale due to the imprecision of the definitions within the scale. Their findings revealed a wide variation among nurses’ interpretation of the scale’s parameters that threatened the integrity of the risk assessment process.
The literature suggests that the Braden Scale be performed for all newly admitted residents to acute, LTC, and home healthcare settings.6 The ability to accurately assess for pressure ulcer risk at the beginning of admission to any setting is key in the healthcare provider’s ability to implement strategies that minimize the risk for pressure ulcer development. The scale should be recalculated when an individual experiences a change in condition, including improvement or deterioration in physical or cognitive functioning. It is also recommended that residents in critical care settings be assessed every 24 hours, that residents in acute care settings be assessed every 24 to 48 hours, and that residents receiving home health services be assessed at every visit. With regard to LTC residents, calculating a Braden Scale score on admission, every week for 4 weeks, and then again either monthly or quarterly is suggested.6 Nursing homes are required to complete quarterly Minimum Data Set assessments (MDS; a federally mandated assessment form used for the development of the interdisciplinary care plan),7 so completing a new Braden Scale assessment at the same time as each MDS assessment may be appropriate. A case vignette demonstrates the considerations and limitations of administering the Braden Scale to an elderly woman with advanced dementia.
Considerations and Limitations When Using the Braden Scale
People with advanced dementia often have altered sensory perception, including the inability to detect pressure, discomfort, or pain from lying in one position for an excessive period of time. These individuals may also be unable to respond to the pressure by turning and repositioning themselves or they may be unable to ask for help. Further, moisture (a separate domain, but poorly defined) includes urine, feces, perspiration, and saliva. Residents with advanced dementia may experience continence issues, particularly when hospitalized and away from their usual routines and caregivers. They may also experience problems with nutrition, as a consequence of either swallowing issues (which are common in the later stages of dementia) or a dependence on others for feeding. Protracted periods of hospitalizations, prescriptive diets that limit salt or sugars, and certain medications or foods that are perceived as unpalatable may negatively impact an older person’s appetite. For these reasons, the Centers for Disease Control and Prevention National Center for Health Statistics reported that residents who experience recent weight loss are more likely to have pressure ulcers than those who do not experience weight loss.8
Although the Braden Scale considers bed-bound residents to be at a higher risk for the development of pressure ulcers than chair-bound individuals, residents may experience more rapid skin breakdown while sitting for prolonged periods in a chair, as the ability to distribute pressure over the pelvis is more limited than when they are lying in a bed. The bed allows pressure redistribution from the head to feet rather than concentrating the majority of the pressure to the buttocks, coccyx, and sacrum. Residents who spend much of their day or many hours at a time in a chair may experience accelerated pressure ulcer development on the posterior pelvis.
With regard to shear, residents who require the head of the bed elevated for respiratory issues or for enteral feedings experience increased friction and shear from the angulation of the blood vessels. This occurs not only when the patient requires a significant elevation in the head of the bed, known as Fowler’s position, but also if he or she has a tendency to slide in the bed or chair due to fatigue or poor trunk control. Issues of friction and shear are also exacerbated through the use of enteral tube feedings that require the patient to be maintained in the Fowler’s position during feedings and for 1 hour after the infusion to reduce the risk of aspiration. Additionally, enteral feedings may produce multiple bowel movements or diarrhea, increasing the risks of fecal contact with the skin and skin breakdown from moisture.
The most problematic area of the Braden Scale for nurses in hospitals, nursing homes, and home health agencies is the fact that having an existing pressure ulcer and/or a history of a healed pressure ulcer are the most relevant factors in determining a patient’s actual risk for developing wounds. The Braden Scale, however, does not identify the presence of a pressure ulcer or the history of a healed pressure ulcer on the risk assessment form. Consequently, a patient may be determined to be at low or no risk for pressure ulcers despite the presence of an actual wound or multiple wounds. In this regard, the nurse must use his or her nursing judgment in conjunction with the patient’s Braden Scale score to determine his or her actual risk for wounds (see section below for additional information). The nurse must also consider whether the patient’s current condition, actual skin integrity issues, history of healed wounds, recent weight loss, use of chemotherapy or steroids, and extensive time on the operating room table may be factors in developing wounds. These are all factors that are not specifically addressed within the six domains of the Braden Scale.
Citing work by Li and colleagues,9 Bergstrom and Horn10 suggested that the prevalence of pressure ulcers among younger black male nursing home residents with diabetes and/or stroke histories is greater than among their white counterparts. However, racial factors, age, and diagnoses are not specifically identified in the Braden Scale and, therefore, may not be fully appreciated as risk factors by the assessing nurse.
Although numerous studies have validated the use of the Braden Scale, Hyun and colleagues11 found that it may not be as predictive in identifying pressure ulcer risk in residents in critical care settings. These residents have a higher incidence of pressure ulcer development than residents in other acute care settings as a result of multiple organ failure, advanced age, or a combination of multiple factors, including nursing workflow issues. The study concluded that further research is necessary to determine whether specific patient characteristics should be used to increase the predictive value of the Braden Scale.
Considerations in End-of-Life Issues
Residents with multiple organ failure, metastatic cancer, an inability to ingest sufficient nutrition to maintain their metabolic needs, and other conditions often seen during the end of life are likely to have an increased risk for the development of pressure ulcers despite the implementation of appropriate interventions. Thomas12 suggested that the goals for residents with terminal illness may be contrary to preventing or healing an existing pressure ulcer. The Braden Scale may not be able to capture all of these clinical conditions and may have limited predictability if the resident is experiencing a very rapid decline in his or her condition. For this reason, special consideration should be given to maximizing the interventions that are able to be maximized, such as providing a pressure-relieving support surface, using an indwelling catheter to divert urine from the skin, employing a fecal collection system to avoid contact between the skin and the stool, and attempting to keep the head of the bed in its lowest position to reduce shear and friction. Facilities may require the staff to perform Braden Scale assessments more frequently for residents who are in the active process of dying or who are rapidly declining. Families should be educated about the process of dying and its impact on the development of pressure ulcers so that they can develop realistic expectations about the purpose and quality of end-of-life care.13
Interventions for Using the Braden Scale Effectively: Key Clinical Questions
Braden revisited her research 25 years after she developed the Braden Scale and concluded that the scale, supplemented with good nursing judgment, provided a reliable method of addressing pressure ulcer risk factors in an individual patient.14 As previously mentioned, to determine risk most accurately, the nursing staff must have the ability to understand the six domains in the Braden Scale, calculate the risk, and then use their nursing judgment to adjust the risk to reflect the condition of the patient. In the example provided in the case vignette, the nurse concluded incorrectly that the patient was at mild risk for developing pressure ulcers when, in fact, the patient already had a stage II pressure ulcer upon admission.
LTC facilities must be cognizant of the need for staff to use their nursing judgment in determining a patient’s risk for developing pressure ulcers. Concluding that a resident is at mild risk or at no risk at all despite having an actual pressure ulcer is an indicator that nurses may be focusing solely on the Braden Scale questions without making their own accurate and appropriate assessments of the individual’s risk. Facilities that have developed wound care policies and procedures based on Braden Scale scores may find an absence or a delay in the implementation of these procedures if the Braden Scale score is calculated inappropriately or if the patient assessment is not taken into consideration in determining an individual’s specific risk for the development of pressure ulcers. The following questions should be asked, followed by the appropriate interventions:
Is the Braden Scale score used as the basis for the implementation of specific policies in terms of support surfaces (beds), dietary consultations, and topical treatments? Is the staff aware of the Braden Scale score that places a patient at high risk? Are LPNs performing most of the Braden Scale assessments? Do they, along with other nursing staff, require specialized education in completing the scale to maximize accuracy? When assessing nutrition, does the staff take into consideration unintentional weight loss, undernutrition, protein-energy malnutrition, and dehydration, all of which are associated with pressure ulcer development?15
Is there a sufficient number of support surfaces in-house or that are available by contract to meet the needs of the residents? Is there a process in place that assures relatively easy access to appropriate mattresses and beds? Is the rehabilitation staff involved in the care of residents with wounds, particularly for positioning and evaluation of support surfaces for the chair? Are residents with impaired bed mobility provided with pillows or other devices to elevate their heels off of the surface of the bed?
Do attending physicians read and act on the recommendations of the dietitian, the wound care team, and others involved in pressure ulcer treatment and prevention? Do physicians defer to the nursing staff for all wound assessments and for care recommendations? Do physicians actually perform assessments of the residents’ wounds during their visits and comment on their conditions? Who is ultimately responsible for the coordination of wound treatment plans in the hospital?
After performing audits of residents who developed stages II, III, IV, unstageable, and suspected deep tissue injury wounds during the course of their nursing home stay, did you determine whether their Braden Scale scores predicted these wounds? If not, is there an opportunity to improve the education of the staff to ensure an understanding of the process of determining a Braden Scale score and the application of nursing judgment to fully appreciate those residents at risk?
When providing in-service education on pressure ulcer prevention, provide a scenario for the staff based on a common set of characteristics. Ask the nursing staff to complete a Braden Scale assessment based on this information, then review each of the six components that comprise the score, providing specific examples of conditions that would indicate that a lower score was appropriate. Following this comprehensive description of the Braden Scale, ask the nursing staff to complete the scale again. Did the scores change?
When auditing charts, does it appear that the Braden Scale scores remained the same throughout the serial assessments of the resident? Is this due to the stability of the resident’s condition, the tendency of the staff to rerecord the same information, or some other factor? Are the Braden Scale scores accurate?
Revisit the policies and procedures for wound prevention and treatment. Does the Braden Scale score drive the use of support surfaces for the bed and chair? If the Braden Scale is miscalculated, is there the potential that the resident who is in need of preventive measures will not receive an appropriate support surface in a timely fashion?
Is the nursing staff encouraged to use their judgment with regard to identifying residents at risk who are above and below the facility’s cutoffs on the Braden Scale that delineate mild, moderate, high, and very high risk for pressure ulceration? Although often predictive of risk, the Braden Scale may be less useful if the scale is not completed correctly or if the nurse fails to take into consideration the fact that an existing wound is already present. An actual wound and/or a history of a healed pressure are the most important factors for understanding pressure ulcer risk despite the fact that these are not part of the present Braden Scale assessment.
Conclusion
The Braden Scale score has become the principle mechanism for determining pressure ulcer risk in individuals admitted to hospitals, nursing homes, and home care settings. The ability to accurately assess for risk at the beginning of admission to any setting is key in the healthcare provider’s ability to implement strategies that minimize the risk for pressure ulcer development. The accuracy of the Braden Scale is dependent on what the assessor perceives as the meaning of the parameters and how he or she understands the individuals’ risk. It requires that facilities encourage and expect the staff to exercise their nursing judgment in determining risk beyond the six components of the scale. Since no risk assessment can completely identify all of the factors that contribute to the development of wounds, LTC facilities should revisit their policies to provide support for nursing judgment to identify residents at risk for wounds beyond the limitations of formal risk assessment scales, including a validated tool such as the Braden Scale. u
References
1. NPUAP pressure ulcer stages/categories. NPUAP website. www.npuap.org. Accessed April 21, 2015.
2. Wound Ostomy and Continence Nurses Society (WOCN). Position statement: avoidable versus unavoidable pressure ulcers. https://bit.ly/PositionStatement_WOCN. Published March 24, 2009. Accessed April 21, 2015.
3. Braden Scale. www.bradenscale.com. Accessed February 15, 2015.
4. 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 [published correction appears in Am J Nurs. 2005;105(8):16]. Am J Nurs. 2005;105(6):70-72.
5. Choi J, Choi J, Kim H. Nurses’ interpretation of patient status descriptions on the Braden Scale. Clin Nurs Res. 2014;23(3):336-346.
6. Ayello EA. Predicting Pressure Ulcer Risk. Hartford Institute for Geriatric Nursing website. https://consultgerirn.org/. Revised 2012; Accessed April 21, 2015.
7. 42 CFR Part 483: Requirements for states and long-term care facilities. Cornell University Law School Legal Information Institute website. www.law.cornell.edu/cfr/text/42/part-483. Accessed April 21, 2015.
8. Park-Lee E, Caffrey C. Pressure Ulcers Among Nursing Home Residents: United States, 2004. U.S. Department of Health & Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics 2009; Data Brief Number 14. www.cdc.gov/nchs/data/databriefs/db14.pdf. Accessed March 20, 2015.
9. Li Y, Yin J, Cai X, Temkin-Greener H, Mukamel DB. Association of race and sites of care with pressure ulcers in high-risk nursing home residents. JAMA. 2011;306(2):179-186.
10. Bergstrom N, Horn N. Racial disparities in rates of pressure ulcers in nursing homes and site of care. JAMA. 2011;302(2):211-212.
11. Hyun S, Vermillion B, Newton C, et al. Predictive validity of the Braden Scale for patients in intensive care units. Am J Crit Care. 2013;22(6):514-520.
12. Thomas D. Prevention and treatment of pressure ulcers. JAMDA. 2006;7(1):46-59.
13. Langemo DK, Black J, National Pressure Ulcer Advisory Panel. Pressure ulcers in individuals receiving palliative care: a National Pressure Ulcer Advisory Panel white paper. Adv Skin Wound Care. 2010;23(2):59-72.
14. Braden, BJ. The Braden scale for predicting pressure sore risk: reflections after 25 years. Adv Skin Wound Care. 2012;25(2):61.
15. Dorner B, Posthauer ME, Thomas D, National Pressure Ulcer Advisory Panel. The role of nutrition in pressure ulcer prevention and treatment: National Pressure Ulcer Advisory white paper. Adv Skin Wound Care. 2009;22(5):212-221.
