Best Practices in Nursing Care to Older Adults
From The Hartford Institute for Geriatric Nursing
New York University, College of Nursing

Issue Number 5, Revised 2007

Series Editor: Marie Boltz, MSN, APRN, BC, GNP
Managing Editor: Sherry A. Greenberg, MSN, APRN, BC, GNP
New York University College of Nursing

WHY: Pressure ulcers (PUs) occur frequently in hospitalized, communitydwelling and nursing home older adults, and are serious problems that can lead to sepsis or death. Prevalence of PUs ranges from 1017% in acute care, 029% in home care, and 2.328% in institutional longterm care (LTC); incidence ranges from 0.438% in acute care, 017% in home care, and 2.223.9% 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 623. 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 subscores 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 subscores 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 careevery 48 hours; critical careevery 24 hours; home careevery RN visit; institutional LTCweekly 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. Its’ validity increases when used in conjunction with the Norton Scale to predict the development of PUs. Interrater reliability between .83 and .99 is reported.

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 cutoff score of 18 or less prevents underprediction of PU risk in these populations.

MORE ON THE TOPIC:
Best practice information on care of older adults: www.geronurseonline.org.

Ayello, E.A., & Braden, B. (2002). How and why to do pressure ulcer risk assessment. Advances in Skin and Wound Care, 15(3), 125132.

Baranoski, S., & Ayello, E.A. (2004). Wound care essentials: Practice principles. Springhouse PA: Lippincott Williams & Wilkins.

Braden Scale. www.bradenscale.com. Last accessed August 9, 2006.

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
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., EmpleoFrazier, 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: 42S50S.

Theodore, J., & Trumble, M.E. (2005). The Braden Scale for predicting pressure sore risk: Reflections on the perioperative period. Journal of Wound, Ostomy, & Continence Nurses, 32(2), 7980.

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. 920047). Rockville, MD: Author.

Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for notforprofit 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.organd/or www.GeroNurseOnline.org. Email notification of usage to: hartford.ign@nyu.edu.

BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK

Patient’s Name _____________________________________
Evaluator’s Name________________________________
Date of Assessment ________________________

SENSORY PERCEPTION
Ability to respond meaningfully to pressure-related discomfort

1. Completely Limited
Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation.
OR
Limited ability to feel pain over most of body.

2. Very Limited
Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness.
OR
Has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body.

3. Slightly Limited
Responds to verbal commands, but cannot always communicate discomfort or the need to be turned.
OR
Has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.

4. No Impairment
Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.

MOISTURE
Degree to which skin is exposed to moisture

1. Constantly Moist
Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.

2. Very Moist
Skin is often, but not always moist. Linen must be changed at least once a shift.

3. Occasionally Moist
Skin is occasinally moist, requiring an extra linen change approximately once a day.

4. Rarely Moist
Skin is usually dry, linen only requires changing at routine intervals.

ACTIVITY
Degree of physicial activity

1. Breakfast
Confined to bed.

2. Chairfast
Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.

3. Walks Occasionally
Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.

4. Walks Frequently
Walks outside room at least twice a day and inside room at least once every two hours during waking hours.

MOBILITY
Ability to change and control body position

1. Completely Immobile
Does not make even slight changes in body or extremity position without assistance.

2. Very Limited
Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

3. Slightly Limited
Makes frequent though slight changes in body or extremity position independently.

4. No Limitation
Makes major and frequent changes in position without assistance.

NUTRITION
Usual food intake pattern

1. Very Poor
Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement.
OR
Is NPO and/or maintained on clear liquids or IVs for more than 5 days?

2. Probably Inadequate
Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement.
OR
Receives less than optimum amount of liquid diet or tube feeding.

3. Adequate
Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered.
OR
Is on a tube feeding or TPN regimen which probably meets most of nutitional needs.

4. Excellent
Eats most of every meal.
Never refuses a meal.
Usually eats a total of 4 or more servings of meat and dairy products.
Occasionally eats between meals. Does not require supplementation.

FRICTION & SHEAR

1. Problem
Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction.

2. Potential Problem
Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.

3. No Apparent Problem
Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.

Total Score________________________

NPO: Nothing by mouth; IV: Intravenously; TPN: Total Parenteral Nutrition

SCORE: 15-16 AT RISK; 13-14 MODERATE RISK; 10-12 HIGH RISK; 9 VERY HIGH RISK

© Copyright Barbara Braden and Nancy Bergstrom, 1988. All rights reserved. Reprinted with permission.