Braden Scale Risk Assessment

The research studies by Bergstrom et al. (1998), Schoonhoven et al. (2002), and VandenBosch et al. (2002) came to similar conclusions in regards to the effectiveness of the Braden Scale in predicting pressure ulcer development in hospitalized patients. Even though the studies found the Braden Scale to be effective, the studies also conclusively suggested, however, that the Braden Scale alone is not sufficient enough to predict at risk patients. Each study, in its own manner, suggested that factors such as the timing of Braden Scale initiation, preventative measures, a consistent and thorough skin assessment, patient clinical status, and inter-rater reliability in staging lesions are discriminatory factors that can all impact the development

of pressure ulcers. Schoonhoven et al. (2002) and VandenBosch et al. (1996) discussed the importance of using the Braden Scale for risk assessment alongside preventative measures for skin breakdown and providing each patient with thorough skin assessments to prevent pressure ulcer development. Among the studies compared, the study by Bergstrom et al. (1998) was the only study that discussed the importance of initial risk assessment screening using the Braden Scale within 48 to 72 hours upon admission to a health care setting.
The sample populations in each study were similar in inclusion criteria. VandenBosch et al. (1996) and Schoonhoven et al. (2002) had inclusion criteria that the participants were over the age of 18, compared to Bergstrom et al. (1998), which required subjects to be at least 19 years of age. In all three of the studies, in order to meet inclusion criteria, participants were to be free of existing pressure ulcers. VandenBosch et al. (1996) conducted their study in a tertiary care setting and had 103 participants. All 103 participants were randomly selected using a random numbers table, daily list of admissions, and an expected hospital length stay of at least one week (VandenBosch et al., 1996). Schoonhoven et al. (2002) used 1,229 participants that were admitted among four different wards at two large hospitals in the Netherlands between January 1999 and June 2000. These participants were required to meet inclusion criteria and have an expected admission of at least five days to be eligible for the study (Schoonhoven et al., 2002). Using randomly selected subjects, Bergstrom et al. (1998) had a sample size of 843 participants, among two tertiary care centers, two Veterans Administration Medical Centers, and two skilled nursing facilities. Participants of the study by Bergstrom et al. (1998) were only considered if they had been admitted to the hospital within 72 hours. The sample populations used in these studies differed among demographics, patient clinical status, reason for hospital admission, and length of hospital stay.
Throughout the research literature, some inconsistencies can be noted. Within the three studies discussed, none of the research literature identified patients that may have had a previous history of pressure ulcer development. Compared to Bergstrom et al. (1998) and VandenBosch et al. (1996), Schoonhoven et al. (2002) only included pressure ulcers of stage II or higher within the study. When comparing Schoonhoven et al. (2002) to the other studies discussed, the exclusion of stage I pressure ulcers cannot be overlooked when interpreting results and data for study comparison. The exclusion of some ulcer stages is one of the major issues related to the design and methods of previous studies. While the most research studies include conducting a proper skin assessment within methodology, in addition to the Braden Scale for risk assessment, it is not always noted if nursing personnel were adequately trained. Both Bergstrom et al. (1998) and VandenBosch et al. (1996) include inter-rater reliability in diagnosing and staging pressure ulcer lesions. It is not known in some of the studies, aside from Schoonhoven et al. (2002), if preventative measures were already in place such as pressure reduction mattresses or regular repositioning of the patient, which may modify risk assessment scores and results. Participants receiving prevention measures, inter-rater reliability of staging lesions, and exclusion of ulcer stages are some of the unanswered questions within the literature that were not addressed and could promote inconsistent results.
Research on the effectiveness of the Braden Scale as a risk assessment intervention in pressure ulcer prevention in hospitalized patients has been demonstrated to be effective based on the literature.

The Braden Scale demonstrated both sensitivity and specificity in risk assessment of pressure ulcer development (VandenBosch et al., 1996). In order to maximize the intervention, it is important that nursing personnel are thorough in skin assessment evaluation and can accurately identify and stage lesions. For future research, it is recommended that a consistent cut-off value be continually updated to determine at risk-hospitalized patients. As previously discussed, a current cut-off value of 18 is used which places patients in a mild risk category of the Braden Scale (Braden & Makleburst, 2005). In this health care practice area, the RN cannot overlook physical assessment. It is recommended that all future research include a proper skin assessment in accordance with hospital policy and procedure. While evidence shows that the Braden Scale is an effective risk assessment tool, it should not stand in for traditional nursing assessment, but rather be used as a tool to help determine at risk patients that are may be in need for further intervention. It is a recommendation that future research study also discuss surgical procedures in relation to the Braden Scale and possible pressure ulcer development. According to Schoonhoven et al. (2002), surgery is considered a risk factor

for pressure ulcer development. Thus, the Braden Scale cut-off values may need to be altered in future research when using surgical patients as participants.
Significance to Nursing Practice
The Braden Scale is an important risk assessment tool in the profession of nursing.

Hospital acquired conditions, such as pressure ulcers, may result in increased hospital stays, increased cost and time management, and other put the patient at risk for other infections. By using a risk assessment scale for skin breakdown, such as the Braden Scale, the RN can initiate preventative measures early and maybe decrease the chance of a patient developing a pressure ulcer. In line with the evidence, the Braden Scale assessment tool should be combined with thorough skin assessment and early initiation of risk assessment screening to maximize the effectiveness of the intervention. Evidence suggests that early initiation of the Braden Scale, within 48 hours of admission, and thorough skin assessment by the RN can not only maximize intervention, but also increase specificity and sensitivity of the Braden Scale. An appropriate Braden Score cut-off value for at risk patients was presented in the studies to be between 17 and 18. The current suggested cut-off value for at risk patients is 18. Hospitals and health care settings use evidence to determine an appropriate cut-off value for their institution. The cut-off value helps determine at risk patients that need further intervention to prevent pressure ulcer development. While there are still some areas for improvement with the Braden Scale as an intervention risk assessment tool for pressure ulcer development, it is still a widely used

and accepted risk assessment scale for hospitalized patients within the profession of nursing.