Predicting Pressure Ulcer Risk – Use of Braden Scale

Abstract

Pressure ulcers are common in older adults receiving care in various environments. Due to its high prevalence and associated high costs, the condition presents a challenge to effective care provision. Identification of individuals at risk of developing the condition thus targeting preventative measures to such individuals would help alleviate the challenge. The purpose of this paper is to evaluate the science behind the use of one of the tools – Braden scale – used to identify individuals at risk of pressure ulcers. From the reviewed literature, Braden scale core strength lies in its reliability and simplicity. Studies on interrater reliability have for instance identified such reliability to be as high as .99. In terms of validity, Braden score has had mixed results as evaluated via sensitivity, specificity, positive predictive value and negative predictive value assays. In sensitivity and negative predictive value, Braden scale rates favorably with values of 59% and 90% and above respectively, in the reviewed studies. The scale however rates unfavorably in specificity and positive predictive with values as low as 26% and 37% respectively, observed in the reviewed literature. Due to the unfavorable observations, reinforcing Braden scale with other risk assessment initiatives would better the process of identifying at-risk individuals, to whom preventative initiatives are focused.

Introduction

With its high prevalence in health care settings such as in acute and chronic care, pressure ulcers presents a clinical and public health concern, whose efficient management may rest with effective identification of at-risk individuals, so as to target preventative initiatives to such individuals (Defloor & Grypdonck, 2005). Among the risk assessment tools developed to assess patients at risk of pressure ulcers are the Norton scale and the Braden scale. Norton scale, being the first of such tools, which was developed in 1962, formed the basis for development of subsequent scales; its risk indicators being redefined or additional indicators being incorporated to supplement those of the Norton scale in the new scales (Defloor & Grypdonck, 2005, p. 374). The Braden scale, which was developed in 1987, is the most commonly employed scale in research, and has been recommended by organizations such as the American Agency for Healthcare Research and Quality (AHRQ) (Defloor & Grypdonck, 2005). The subject of this paper is to review the science behind the use of the Braden Scale. Specifically, the paper, through the review, seeks to assess the appropriateness of the tool for use in the care provision for the older adults.

The Braden scale quantifies the risk of pressure ulcers based on summative scores of an individual’s rating in each of the six items that make up the scale (Defloor & Grypdonck, 2005; Vap & Dunaye, 2000). The six items are sensory perception, moisture, activity, mobility, nutrition and friction or shear ((Defloor & Grypdonck, 2005, p. 374). Except for the last item (shear) whose rating ranges from 1 to 3, all other items are rated from 1 (least favorable scenario) to 4 (most favorable scenario) (Defloor & Grypdonck, 2005; Vap & Dunaye, 2000). Accordingly, the maximum possible score (indicating the least risk for pressure ulcers) is 23, being a scoring of 4 in the five items and 3 in the in the sixth item. The lower the score, the higher the risk of pressure ulcers, with scores equal to or lower than 12 being considered to be high risk cases (Defloor & Grypdonck, 2005; Vap & Dunaye, 2000). Mild risk is indicated by scores of 16 or 17 (Vap & Dunaye, 2000). Go to part 2 here.

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