March 8th, 2012
By Jennifer Olin, BSN, RN
Decubitus ulcers or pressure ulcers, or as they are more commonly known, bedsores, are nursing practice priorities across all healthcare settings. From the nursing home to the operating room and everywhere in between, maintenance of skin integrity is a major aspect of nursing care. Consistent, planned skin care assessment and interventions are critical to ensuring high quality care.
A pressure ulcer is a localized area of tissue necrosis (death) that develops when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time.
Nurses cannot expect to make significant progress in preventing pressure ulcers if pressure ulcer risk assessment, prevention planning, prevention intervention, and outcomes evaluation function as distinct and unrelated activities. The mandate to proceed systematically to assess, diagnose, plan, implement, and evaluate is as relevant for managing pressure ulcer risk as it is for managing any other clinical condition.
Pressure Ulcer Staging
Pressure ulcers are defined in stages, how far tissue breakdown or necrosis has advanced.
Implications of Pressure Ulcers
Studies have revealed that pressure ulcers produce endless pain, restrict activities, and require a significant amount of coping on the part of the patient. The persistent pain is simply caused by the need to move (leading patients to lay still), the pain associated with dressing changes, and debridements. Pressure ulcers cause depression, anxiety, feelings of being burdensome, powerless, and inadequate. Wound odor affects both the patient and the people around them.
Pressure ulcers can take months to heal and involve elaborate surgical procedures, which are also painful. Pressure ulcers can impose severe financial and social burdens on families. The cost to treat pressure ulcers is over one billion dollars annually and there is an additional 2.2 million Medicare hospital days added to the healthcare system. The cost of treating ulcers is at least 2.5 times the cost of preventing them at $2000-$40,000 per pressure ulcer, depending on the stage of development.
Another issue, besides patient health and safety, which is of course the primary concern, are the recent changes in compensation for hospital acquired pressure ulcers. If they become rated at Stage III or Stage IV and could have reasonably been prevented it is very likely the healthcare facility will not get paid for the pressure ulcer treatment.
The Braden Scale for Predicting Pressure Sore Risk was developed during a Robert Wood Johnson Teaching Nursing Home project and while writing an NIH proposal to study pressure ulcer risk factors. This tool is in use on all continents and has been translated into many languages. Of the many risk assessment tools available the Braden Scale has demonstrated the best reliability and validity. It has been tested in the largest number of studies, has demonstrated the best reliability and validity indicators in a variety of settings, and has proven to be a better predictor of pressure ulcers than nursing judgment.
Braden Scale Criteria
The Braden scale assesses a patient's risk of developing a pressure ulcer by examining six criteria:
Braden Scale Scoring
Each of the six categories is rated on a scale of one to four, excluding the 'friction and shear' category which is rated on a one to three scale. This combines for a possible total of 23 points, with a higher score meaning a lower risk of developing a pressure ulcer and vice-versa. A score of 23 means there is no risk for developing a pressure ulcer while the lowest possible score of six points represents the severest risk for pressure sore development. An adult with a score below 18 is considered to at high risk.
Using the Braden Scale not only identifies people at risk for getting a pressure ulcer but also provides information to help plan prevention interventions. Nurses should keep a copy of the Braden Scale at their fingertips (currently there is no Braden Scale app for the iPhone).
It was once thought that nurses needed no additional training to determine how to use the Braden Scale correctly. More recent research suggests that training on how to correctly use the Braden Scale is needed to improve the reliability of Braden Scale risk assessments made by RNs working in acute care hospitals. Even if a nurse has used the Braden Scale for a long time that does not mean that all of his or her pressure ulcer risk assessments are reliable. Research has shown that considerable room for improvement exists in the reliability of Braden Scale assessments made by nurses who regularly use the assessment tool. Brushing up on the Braden Scale risk assessment technique through annual competency training is recommended for all health care practitioners.