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Pressure Ulcer Risk Factors And Appropriate Assessment Tools: A Literature Review

Pressure Ulcer Risk Factors And Appropriate Assessment Tools: A Literature Review

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An essay for the 2011 Undergraduate Awards Competition by Laura Coyne. Originally submitted for Research Project (Theory) at National University of Ireland Galway, with lecturer Ms Claire Welford in the category of Nursing & Midwifery
An essay for the 2011 Undergraduate Awards Competition by Laura Coyne. Originally submitted for Research Project (Theory) at National University of Ireland Galway, with lecturer Ms Claire Welford in the category of Nursing & Midwifery

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Pressure ulcer risk factors and appropriate assessment tools: A literature Review.

Laura Coyne 07024711

A Focused Literature Review submitted to the School of Nursing and Midwifery, National University of Ireland, Galway

As part requirement for the degree of Bachelor of Nursing Science Of The National University of Ireland, Galway

December, 2010

Supervisor: Ms Claire Welford


School of Nursing and Midwifery National University of Ireland, Galway

Declaration Form Focused Literature Review A signed Declaration Form must be submitted with each copy of the Focused Literature Review.


Bachelor Of Nursing Science 4NG4


Focused Literature Review -Pressure Ulcer Risk Factors And Appropriate Assessment Tools: A Literature Review-

Name: Laura Coyne Student Identity No: 07024711 Date Submitted: 06/12/2010 Word Count: 4,400

I hereby declare this work is entirely my own and that I have acknowledged the writings, ideas and work of others. Furthermore I have not knowingly allowed another to copy my work.


__________________________ Date:


I hereby agree that the copy of my Focused Literature Review submitted to the School of Nursing and Midwifery, NUI, Galway should be available for consultations under the conditions laid down by the Head of School.


__________________________ Date:



This focused literature review* aims to critically review the literature in relation to the factors that predict pressure ulcer development. Another aim of this review involves analysing the literature to assess which pressure ulcer risk assessment scale is most validated in terms of specificity, sensitivity and inter-rater reliability. The scales which will be discussed include the Braden, Norton and their modifications as well as the Waterlow Scale. Although 95% of pressure ulcers are preventable they still remain a huge health care burden in terms of cost and on the quality of care patients receive (Clark, 2002 and Fox, 2002). Therefore, it is vital that nurses are educated on the different predictors for pressure ulcer development. The literature highlights several different risk factors associated with pressure ulcer development. It also illuminates the importance of early recognition of these predictors in order to implement appropriate preventative interventions. Risk assessment scales are used to aid nurses in accurately identifying patients at risk of pressure ulcer development. The research reports that there is no evidence indicating that the use of risk assessment scales decreases pressure ulcer incidence. However it has been identified that the use of scales in conjunction with clinical judgement increases the intensity and effectiveness of prevention interventions. A critique of the literature focusing on the risk factors for pressure ulcer development and the most validated and reliable risk assessment scale available will assist nurses in informing their practice through being able to identify at risk patients using the best tool available. This will allow nurses to put a preventative strategy in place contributing to a high quality of care.


Literature Review: is an organised written presentation of what has been published by scholars. Its purpose is to convey to the reader what is known in relation to the topic.


I would like to acknowledge the support Of Ms Claire Welford for her dedicated time and effort in contributing to the development of this focused Literature Review. I also wish to thank my family and friends for all their tremendous support through this project.


Table of Contents




Literature Review Method:


Literature Review:

Section One: Identifying Risk Factors For Pressure Ulcer Development


Section Two: Using Risk Assessment Scales To Assess For Pressure Ulcer Development 9

Discussion and Conclusion:


Reference List:




This focused literature review aims to critically analyse the literature in relation to the factors which predispose patients to developing a pressure ulcer in an acute care setting. Another aim of this review involves scrutinising the literature in relation to the most validated risk assessment scale available to assess patients for their risk of pressure ulcer development.

A pressure ulcer has been described as, “localised damage to the skin caused by disruption of the blood supply to the area, usually as a result of pressure, shear or friction or a combination of any of these” (Dealey 2005, p.121).

Gunningberg et al., (1999) notes that 95% of pressure ulcers are preventable and nursing care is believed to be a primary method of preventing pressure ulcer development. Therefore, accurate identification of at risk patients using a reliable and valid pressure ulcer risk calculator is the first step in preventing pressure ulcer development (Buttery and Phillips, 2009, Flanagan, 1993, Davis, 2004, Pang and Wong, 1998). European figures suggest that approximately 18% of hospitalised patients have an ulcer at any time (European Pressure Advisory Panel, 2002) (EUPAP). In Ireland, two prevalence studies carried out in the acute care setting confirmed the extent of the problem and found that prevalence lies between 12.5% and 21% (Moore et al., 2000).


Not only are pressure ulcers damaging to a patient‟s quality of life, they also pose a huge financial burden to the health care system. Gethin et al., (2005) estimate the cost of treating one patient with a grade 4 pressure ulcer successfully at €119,000 and that it costs €250,000,000 per annum to manage pressure ulcers across all care settings in Ireland. Nurses need to be aware of the indications for pressure ulcer development and educated on the most reliable and validated risk assessment scales (O‟Brien, 2002). A risk assessment scale for pressure ulcer prevention is a tool for establishing a score according to a series of parameters considered to be risk factors. Some of the most widely used scales include, the Norton Scale, Braden Scale and their modifications and the Waterlow scale (Thomas, 2001).

A review of the literature regarding pressure ulcer prevention through the early detection of risk factors using an easy to use, reliable and validated risk assessment tool is pivotal to prevention (Ayello, 2009 and Dealey, 2005).


Literature Review Method
In order to obtain literature for this review, five electronic databases were used. These databases were CINAHL, Health Source Nursing, MEDLINE and Blackwell Synergy. These major databases were selected as they have been deemed to be the most relevant databases for nurses (Aveyard, 2010).

Initially the keywords “Pressure Ulcer” and “Prevention” were searched as these captured the essence of the topic resulting in a large number of hits. In order to ensure that the articles retrieved were up to date, relevant and of the highest quality, certain criteria were put in place prior to conducting the search (Parahoo, 2006). This included selecting a time frame for the published papers from 1990 to 2010 and ensuring that they were peer reviewed. In order to constrain the search, combinations of the keywords were used using the Boolean characters “AND”; “OR” for example when pressure ulcer and prevention were used this resulted in 1101 hits. When pressure ulcer and prevention and assessment were used 416 hits were obtained. To decide whether or not the studies found were pertinent to the selected review topic, the abstracts were read first. The papers with abstracts that appeared useful were then downloaded, carefully read and evaluated for the literature critique using the framework suggested by Timmins and Mc Cabe (2005).


Twenty research papers were thus deemed appropriate for the review. All of the search articles sourced were found to be quantitative*. Once the articles had been classified and their references assessed for usefulness, emphasis moved onto carefully scrutinising the information and highlighting common themes needed for the review.


Quantitative Research: consists of stating, in advance, the research questions or hypotheses, operationalising the concepts and devising or selecting in advance the methods of data collection and analysis. The findings are presented in numerical/statistical language.


Literature Review The review of the identified literature highlighted two key themes. Section 1 will discuss the different factors which best predict the development of pressure ulcers. Section 2 will examine how the use of risk assessment scales and clinical judgement can impact on the effectiveness of pressure ulcer prevention. Finally the review will conclude with recommendations for research, education and practice.

Section 1: Identifying Risk Factors Many studies have highlighted the importance of identifying certain risk factors for pressure ulcer development which prompt efficient application of preventative measures. (Nonnemacher et al., 2008, Chan et al., 2009, Lindgren et al., 2004, Wann-Hansson et al., 2008, Zhan and Miller, 2003, Krause et al., 2005, Gunningberg et al., 2001, Fogerty et al., 2008, Reed et al., 2003, Williams et al., 2000.)

A quantitative study carried out by Wann-Hansson et al., (2008) had two aims. The first was to identify risk factors associated with hospital acquired pressure ulcers among patients in an acute hospital compared with patients with pre-existing pressure ulcers present on admission. The next was to establish the preventative measures performed with both groups. A point prevalence study with a cross sectional survey design was carried out on 535 patients. This

study determined that pressure ulcers are a significant problem in acute hospital care with a prevalence of 27%. Vanderwee, (2007) agrees that this is statistically high given that the incidence of pressure ulcers ranges from 0.4-38% in acute care hospitals. Risk factors found to be associated with pressure ulcer development included, a higher age a total Braden risk assessment score below 17 and friction and shear while seated or lying down. The findings in this study are credible as a good sample size was used which is likely to be representative of the target population (Polit and Beck, 2006). A modified version of the one page data collection protocol developed and tested by the EUPAP group was used, ensuring that the tool was reliable and validated and so, accurately measuring what it is supposed to measure (Gunningberg et al., 2006). Training was given to nursing staff to ensure that data was accurately collected and in order to prevent bias a ward nurse and non-ward nurse both assessed the patient (Parahoo, 2006). Mann-Whitney U and Chi-square tests were used to identify comparisons between the groups ensuring results were due to real differences and not due to chance (Clegg, 1990). However this study is not without its limitations which were noted within the text. Firstly, prevalence studies are usually snapshots of a particular problem at a particular time and place and need to be interpreted with some level of caution (Baumgarten, 1998). There is always a risk of inconsistency in ratings and assessments between different people. It is also of value to note that about half of the pressure ulcers documented were classified as Grade 12. Halfens et al., (2001) found in a previous study that these were reduced by 50% on a second assessment, therefore Grade 1 ulcers could be excluded from the study.

In addition, a quantitative study used a survey design to determine the combination of risk factors which predicts the risk of developing pressure ulcers. Nonnemacher et al., (2008) used data from a large prospective cohort study established to investigate pressure ulcers in

an acute care setting. The study population (n=34,238) presented with different characteristics which were not dominated by one or more high risk groups thus avoiding any methodological limitations (Halfens, 2000 and Lyne et al., 2000). Information on pressure ulcer status and potential risk factors was collected by trained nursing staff and checked by a senior nurse weekly to avoid information bias (Burns and Grove, 2005). The potential risk factors were derived from a review of existing risk assessment scales and German guidelines for prophylaxis of pressure ulcers (Lottko et al., 2004). Some of the risk factors were only documented for adults and others for children and data for both was pooled for analysis which could affect results as all research findings obtained from adults may not be transferrable to children due to their anatomical, physiological and psychological differences. According to Lyne et al., (2000) multivariate logistic regression, which was used in this study, is best used to identify risk factors for the prediction of pressure ulcers. The results found are in accordance with those of the previous study concluding that limited mobility and the problems of friction and shearing forces are predictors in pressure ulcer development. Furthermore, this study illuminated the presence of malignant tumours, pain, prescription of drugs with a sedative effect, arterial obstructive disease and insufficient hydration and nutrition as risk factors. An interesting discovery in this study revealed that incontinence is not a risk factor for developing pressure ulcers, which is supported by Reed et al., (2003) and Krause‟ et al., (2005) investigations. Even though Zhan and Miller (2003) suggest that the exposure to risk factors can confound results, the quality of the data, sample size and characteristics of this study‟s population bode well for the ability to generalise results. Similar results were obtained in two quantitative studies by Willimas et al., (2000) and Reed et al., (2003). The latter study (n=2,771) used a longitudinal cohort design and data collected as a component of a multi-site controlled clinical trial. Results determined that impaired


mobility, malnourishment, hypoalbuminemia and confusion are risk factors in pressure ulcer development.

A further quantitative study by Lindgren et al., (2004) reported from a prospective comparative study of 530 patients that immobility is a risk factor of major importance for pressure ulcer development. Trained nurses collected the admission data and subsequent data once a week for up to twelve weeks. The instrument used was the validated and credible Risk Assessment Pressure Sore Scale3. Results were compiled from admission data and multiple stepwise logistic regression analysis was used to elucidate significant risk factors from factors already identified. Tabachnick and Fidell (1996) suggest that the use of statistical models allows one to predict an outcome from a set of variables. The study also identified patients with increased age, lower BMI, diastolic blood pressure and score on the risk assessment pressure scale as being at risk. Similarly, Chan et al., (2009) study also concluded that altered sensory perception, body-build for height and skin type were significantly predictive of pressure ulcer development. Unfortunately in the regression analysis, the variables friction and shear were excluded because of their correlation to mobility however, shear and friction are regarded as extrinsic factors associated with pressure ulcer development and therefore should not have been excluded (Kosiak, 1959). One study by Gunningberg et al., (2001) examining the nurses knowledge and documentation of risk of pressure sore development, found that avoiding shearing force was infrequently mentioned and not documented, statistically, this was not a large group as only 41 (68%) of nurses replied to the questionnaire, however, this study is a compliment to earlier studies performed on other samples (Lindholm et al., 2001).


In addition to the studies reviewed, Fogery et al., (2008) carried out a retrospective analysis on a stratified, cross-sectional, nationwide database using a survey in order to analyze suspected risk factors contributing to pressure ulcers. The sample (n=94,758), had a discharge diagnosis of pressure ulcer, identified by the International Classification of Diseases. AfricanAmerican race and advanced age were identified as risk factors. Disorders of skin integrity, organ system failure, and infection were also found to be broad categories of risk factors leading to pressure ulcer development. This study used the Nationwide Inpatient sample, a large American nationally representative database rendering the findings generally applicable to the pressure ulcer population across the US. However, there may have been errors in results as coding inaccuracies were missing for 26.7% of all patients, there was negligence issues such as the failure to check for the presence of an ulcer upon discharge or the tendency to under report pressure ulcer development.

In summary, the aforementioned risk factors identified in the studies leave patients at risk for the development of pressure ulcers. Recognition of these factors by nurses is pivotal for the timely application of preventative measures. The next section will focus on the validity the different risk assessment scales and there use in assessing patients in an acute care setting.

Section 2: Using Risk Assessment Scales An analysis of the literature revealed that risk assessment scales are used in order to accurately identify patients at risk of developing pressure ulcers. Of the studies which have explored this many have reported that there is no evidence indicating that the use of risk

assessment scales decreases pressure ulcer incidence. However, the use of scales in conjunction with clinical judgement increases the intensity and effectiveness of prevention interventions. The most commonly used scales are the Waterlow, Braden and Norton (Appendix 4
and 5)

scales and many of the research papers focused on testing the validity of these scales.

Saleh et al., (2009) using a pre-test/post-test experimental design sought to determine whether the use of risk assessment scales alone reduces pressure ulcers or could nurse education, the use of clinical judgement, or both have an effect. Using a Braden risk assessment score of <18 to determine those at risk, patients were randomly allocated into nine wards which were randomly split into three groups. Group A (Braden Scale Group) were given training on pressure ulcer prevention and the application of the Braden Scale, Group B (Training Group) were identical to A but not required to implement the scale and Group C (Clinical Judgement Group) received only a mandatory wound care management study day. A clinical judgement rating scale was devised, this instrument was validated and reliable as they conducted a pilot study which ensured that the scale was clear and unambiguous (Russell, 2005). The result of the study determined that there were no significant differences between the three groups for pressure ulcer incidence in the pre-intervention and postintervention phases. However, results showed that there was a decrease in pressure ulcer incidences across the board. Unfortunately the sample size used is not specified within the article, making it difficult to assess the value of the results (Burns and Grove, 2005). It is possible that results could be affected by other variables such as the use of pressure relieving devices, nurse‟s previous experiences with scales or patients‟ medical diagnosis. Polit and Beck (2006) agree and state that independent variables could affect the results of the study. The study also suggests that clinical judgement is as effective as a risk assessment scale in terms of assessing risk and determining appropriate care though neither show good

sensitivity* nor specificity* in this particular study.

Further studies by Smith (1989),

Salvadelena et al., (1992) and Vandebosch et al., (1996) have identified that nurses‟ clinical judgement has reasonable sensitivity at roughly 50% in identifying patients at risk of pressure ulcer development. However, it is important to highlight that these studies do not give data on the nurses‟ experience. This is important as the ability to provide a correct clinical judgement is greater among experienced nurses (Garcia-Fernandez et al., 2006). This was evident from Buhrer and Mitchells (1996) study. They found that although experienced nurses initially used the same factors as those included in the major risk assessment scales (Braden, Norton, Waterlow), they weighed each factor giving greater weight to weight and nutrition. What is more they took into consideration up to 35 factors not included in these scales but which helped them to gauge the actual risk of each patient. Therefore, assessing pressure ulcer risk is a complex process employing both a thorough overall assessment and the use of skills resulting from experience and intuition.

In contrast to this previous study‟s findings on the Braden scale as a predictor for pressure ulcer development, a systematic review carried out by Pancorbo-Hidalgo et al., (2006) concluded that the Braden scale is considered to have optimal validation. Bergstrom et al., (1987a) and Ramundo (1995) found its sensitivity between 100% and 38.9%, Hagisawa and Barbenel, (1999) found its specificity ranges from 100% to 26% (Seongsook et al., 2004), and positive predictive value between 100% and 4.5% (Hagisawa and Barbenel, 1999 and Lewicki et al., 2000). It is noted by the authors that the Braden Scale offers above other scales the best balance between sensitivity and specificity. They also found the Braden scale

Sensitivity: is the ability of the score to predict all those who will contract a pressure sore. Specificity: is the extent to which the absence of the characteristic is correctly classified



to be a better predictor than the Norton and Waterlow scales. In addition to this, findings suggested that inter-rater reliability is high between nurses.

It was evident from the literature that the Braden scale has been found to be the most predictive (Pang and Wong 1998, Berquist and Frantz 2001 and Seongsook et al., 2004). However further studies have recommended that it can be enhanced and that added subscales can strengthen its predictive validity (Halfens et al., 2000, Defloor and Grypdonck 2005 and Kring 2007). Chan et al., (2009) compared the predictive validity of the Braden and modified Braden scales6 and found that, 9.1% of 197 subjects assessed for their risk of pressure ulcer development developed pressure ulcers. The Modified Braden Scale with a cut-off score of 19 showed better predictive validity than the Braden Scale in predicting patients at risk and those not at risk of developing a pressure ulcer. This prospective cohort study however was limited to a small sample size in an orthopaedic setting and as such applies only to this setting. A further limitation is that this study was not a random study and as such there is no guarantee that the sample will be representative of the population (Polit and Beck 2006). The data was collected by a researcher and an experienced nurse trained to use the modified Braden scale and the third variables of patient characteristics were tested in order to examine the differences in patient characteristics thus achieving significant substantial results (Burns and Grove, 2001). However, one must always consider the possibility of nurses being more thorough in assessment and in the application of preventative measures as they were aware of the study.

An evaluation of the literature revealed that the use of the Norton Scale increases the intensity of preventative interventions. According to the literature it stands in second position

to the Braden scale in terms of validity ranking. Hodge et al., (1990) carried out a quantitative study with a pre-test/post-test design. This study aimed to assess how the use of the Norton Scale effects the implementation of preventative care used by nurses. Senior nurses, supervisors and nurses working in the four units that took part in the study attended a course on the use of the Norton Scale as a care planning tool, ensuring that they could use it effectively. A non random sample was used which consisted of 181 patients, 89 in the experimental group and 92 in the control group. The experimental group used the Norton Scale during their assessment whereas the control group did not. In the follow up period results highlighted that there was a clear increase in the frequency and precociousness of preventative interventions used in the experimental group. Results may have been affected by a number of factors including greater nurse awareness, a stage system was not used for classification and some preventative interventions used were ineffective.

In addition, the Norton scale has been modified (MNS)7 in order to better describe the patient‟s risk of developing a pressure ulcer. One quantitative study using a prospective design, with an experimental and control group assessed whether the use of the MNS could identify patients at risk for developing pressure ulcers. Another aim of the study was to compare the reported prevalence of pressure ulcers in the experimental group compared with a control group. (Gunningberg et al., 1999). In order to assist in the nurse‟s assessment a Pressure Ulcer Card was developed consisting of the MNS and descriptions of the four stages of pressure ulcers. This card attained validity and reliability prior to the study, Burns and Grove (2005) comment, that the researchers should indicate how the reliability and validity of the adapted instrument was established. The small sample consisted of 124 patients who were allocated consecutively to either the experimental group or control group. The intervention in the experimental group consisted of risk assessment, risk alarm and skin

observation performed by a nurse, in the A and E department and daily throughout the hospital stay. The control group was assessed in the A and E department and at discharge. Results of the initial assessment in A and E were not made available to the nurses on the wards, preventing any influence in their assessment. On arrival to hospital, ≈20% of patients in both groups had pressure ulcers. At discharge, the rate had increased to 40% in the experimental group and 36% in the control group. Results make it evident that there was no significant difference found between the prevalence of pressure ulcer development in the control and experimental groups. However, results clarify that the use of the MNS made it possible to identify the majority of patients at risk for pressure ulcer development. The sensitivity was determined to be 71% and the specificity was 44% (Polit and Beck 2006).This proves that the systematic use of the MNS is conducive in assisting nurses in identifying risk (Bale et al., 1995). Factors which influenced results include that there were more missed assessments at discharge in the control group compared with the experimental group, the nurses were not trained in assessment, it is possible that the nurses in the control group were more reluctant to report pressure ulcer development and data was also found to be missing in the pressure ulcer card documentation.

A further quantitative study undertaken by Bääth et al., (2008) used a cross-sectional design. Its aim was to assess the inter-rater reliability between registered and enrolled nurses in using the MNS. A total of 228 paired assessments were undertaken on 114 patients. The sample included 50 registered nurses and 61 enrolled nurses. The differences between the two independent groups was analysed using a student‟s t-test for age and work experience, differences were considered significant. It is interesting to note that the different educational levels between the two groups do not seem to influence the agreements to a greater extent. Only a few RNs and ENs had received further education about pressure ulcers, apart from

what is included in their regular nursing education. It was evident from the high agreement level in the present study that RNs and ENs make similar assessments using the MNS as a risk assessment tool as it is understandable and easy to utilise. Both the RN‟s and EN‟s received adequate training in assessment prior to the study and assessed each patient individually without consult in order to avoid bias.

Issues around the validity and inter-rater reliability of the Waterlow scale were raised by some authors in the literature. Recent studies have identified weakness in the tool, such as poor predictive validity, particularly the tendency for the tool to overestimate the number of patients at risk (Wai-Han et al., 1997, Westrate et al., 1998 and Schoonhoven et al., 2002). In a quantitative study with a longitudinal cohort study design 200 eligible patients were tested in order to assess the validity of the Waterlow tool. Patients used in the study were expected to remain admitted for at least three days, their baseline demographics and their pressure ulcer status was assessed on admission and recorded every second day by a trained research nurse using the Waterlow scale as well as a survey tool to identify risk factors. Results of the assessment with the Waterlow scale reflect those of the studies previously mentioned and find that 45 (22.5%) participants scored >15 indicating they were at risk. Of these 6 (13.3%) did so, compared with 3 of the 155 (1.9%) who were not identified as at risk. This study provides evidence of poor predictive validity associated with the Waterlow Scale. The limitations of this study include, a small sample size, in some cases it was not possible to directly view all of the patient‟s pressure points, information regarding the patients skin was obtained by asking the nurse caring for the patient or by extracting information from records. It is possible that this may have lead to an underestimation of the true pressure ulcer incidence. Furthermore, the literature would suggest that there is poor inter-rater reliability among nurses using the Waterlow risk assessment tool. Kelly (2005) and Edward‟s (1995)

studies aimed to ascertain whether a lack of inter-rater reliability with the Waterlow scale is due to different perceptions of patients by nurses, or different interpretations of Waterlow as a tool. Results suggest that nurses are not using the tool in the way it was intended and thus complicating the correct implementation of care.

Discussion and Conclusion
Schoonhovan (2007) writes that the cornerstone of prevention is to assess and manage the risk before an injury occurs. It is evident from the research that higher age, immobility, friction and shearing forces while seated or lying down, the presence of malignant tumours, pain, prescription of drugs with a sedative effect, arterial obstructive disease, insufficient hydration and nutrition with associated hypoalbuminemia as well as confusion are all linked with pressure ulcer development (Wann-Hansson et al., 2008, Nonnemacher et al., 2008, Lindgren et al., 2004, Gunningberg et al., 2001, Williams et al., 2000, Reed et al., 2003). Many other studies highlighted that a lower diastolic blood pressure, altered sensory perception and body mass index, skin type, disorders of skin integrity, organ system failure, being of an African-American descent and infection are risk factors (Chan et al., 2009, Fogerty et al., 2008 and Reed et al., 2003). It is of interest to note that certain studies have identified that incontinence is not a risk factor in pressure ulcer development (Williams et al., 2000, Nonnemacher et al., 2008, Krause et al., 2005).

After reviewing the literature it is evident that the most common risk assessment tools used are the Norton, Braden and Waterlow scales. It was distinguished throughout the literature that the ideal assessment scale should demonstrate good predictive value, high sensitivity and specificity and be easy to utilise. (Saleh et al.,2008, Pancorbo-Hidalgo et al., 2006,

Gunningberg et al.,1999). An evaluation of the literature revealed that the Braden Scale

offers above other scales the best balance between sensitivity and specificity, is a better predictor and has high inter-rater reliability ( Pancorbo-Hidalgo et al., 2006, Hagisawa and Barbenel, 1999, Seongsook et al., 2004, Pang and Wong 1998, Berquist and Frantz 2001). However, further studies have suggested that the Braden scale can be enhanced with subscales in order to strengthen its predictive validity (Halfens et al., 2000, Defloor and Grypdonck 2005, Kring 2007 and Chan et al., 2009)

The Norton Scale and the Modified Norton Scale stands in second place in terms of validity ranking. The Norton Scales‟s sensitivity and positive predictive value can be considered reasonable (Hodge et al., 1990, Gunningberg et al., 1999). There was a lack of studies located that deal with the Norton Scales inter-rater reliability, however one study located found its inter-rater reliability very good (Bääth et al., 2008). Therefore, further validation on this scale is needed, including an analysis of inter-rater reliability.

The studies carried out on the Waterlow Scale reveal that it has poor predictive validity and a tendency to overestimate the number of patients at risk, leading to preventative measures being applied to patients not in need of them (Wai-Han et al., 1997, Westrate et al., 1998, Schoonhoven et al., 2005, Edwards 1995, Webster et al., 2010).

It is evident from the review that the use of risk assessment tools should be used in conjunction with clinical judgement. As other studies have determined that clinical judgement has reasonable sensitivity in identifying at risk patients (Saleh et al., 2008, Smith 1989, Salvadelena et al., 1992, Vendebosch et al., 1996).

It is recommended that in order to prevent pressure ulcers all nurses should be provided with regular in service training on how to identify the different risk factors associated with pressure ulcer development and on how to assess patients using a reliable tool, incorporating their clinical judgement and intuition. This will ensure an overall thorough assessment is carried out and result in appropriate preventive care being provided for suitable patients.


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Braden Scale Sensory/Mentally Moisture Activity Mobility Nutrition Friction/Shear

1.Totally Limited

1. Constantly Moist

1. Bedfast

1. 100% Immobile

1. Very Poor

1. Frequent Sliding

2.Very Limited

2. Very Moist

2. Chairfast

2. Very Limited 3.

2. < daily portion 3. Most Of Portion 4. Eats Everything

2. Feeble Corrections 3. Independent corrections

3.Slightly Limited



Occasionally Walks Slightly Moist w/assistance Limited 4.No Impairment 4. Dry 4. Walks w/out assistance 4. Full Mobility

Total Braden Scale =
15-16 Mild Risk 12-14 Moderate Risk <12 High Risk 15-18 Is Considered Mild Risk For Those > 75

Braden BI, Bergstrom N. Clinical Utility of the Braden Scale for Predicting Pressure Sore Risk, Decubitus, August 1989, 2: 44-51.


Staging Of Pressure Ulcers

Stage I ulcers are indicated by damaged friable surface skin with considerable hidden cell death caused by continuous pressure damage usually from immobilization in a single position. Identification of signs of pain and early indications of visible damage is a significant event in that it alerts caregivers of the need for interventions to prevent more serious damage. Stage II ulcers present as partial thickness wounds, which may heal with early intervention by regeneration under advanced wound care techniques. Stage III ulcers are usually full-thickness pressure sores. These are often difficult to classify due to the presence of eschar that obscures visualization of the wound bed. The presence of eschar does indicate a full thickness wound but the eschar must be removed (debrided) before classification can be established. Early Stage III or Stage IV pressure ulcers may superficially resemble Stage I ulcers. A wound initially classified as Stage I may, therefore subsequently appear to progress to higher stages as the already damaged deeper tissues slough off or as autodebridement occurs with moist wound healing therapy.

Stage IV ulcers are characterized by full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining of healthy surrounding skin and sinus tracts may also be associated with Stage IV pressure ulcers. Worldwide Wound Management, (2008-2017).


Risk Assessment Pressure Sore (RAPS) Scale The assessment scale used, the Risk Assessment Pressure Sore (RAPS) scale is a further development of the modified Norton scale. The development has been made in an attempt to improve the predictive ability of the scale. The RAPS scale contains the following variables: general physical condition, activity, mobility, moisture, food intake, fluid intake, sensory perception, friction and shear, body temperature and serum albumin level. The variable friction and shear are rated from 1 to 3 and the remaining variables from 1 to 4. Serum albumin was coded into four levels: the highest level 4, 36–42 g/L; level 3, 32–35 g/L; level 2, 26– 31 g/L; and the lowest level 1, 25 g/L or less. The scale is an additive scale ranging from 10 to 39 points and the lower the score the greater the risk of pressure sore development.





Appendix Norton Scale

Physical Condition Mental Condition Activity Good Fair Poor 4 3 2 Alert 4 Ambulant Walk-Help 4 3

Mobility Full

Incontinent 4 Not Occasional 4 3

Apathetic 3 Confused 2 Stupor 1

Slightly Limited 3 2 1

Chair bound 2 Very Limited Stupor 1 Immobile

Usually Urine 2 Doubly 1

Very Bad 1

The range of possible total scores varies between 5 and 20, with an arbitrary cut-off score of 14, which equated to the individual being „at risk‟


Modified Braden Scale
For children < 5 years
Mobility Completely immobile: Does not make even slight changes in body or extremity position without 1 assistance. Very limited: Makes occasional slight changes in body or extremity position but unable to completely turn 2 self independently. Slightly limited: Makes frequent though slight changes in body or extremity position independently. 3 No limitations: makes major and frequent changes in position without assistance.4

Affix patient identification label in this box)



Bedfast: confined to bed. 1 Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. 2 Walks occasionally: walks occasionally during day, but for very short distances, with or without 3 assistance. Spends majority of each shift in bed or chair. All patients too young to ambulate: OR walks frequently. Walks outside the room at least twice a day 4

Sensory Perception

Completely Limited: Unresponsive (does not moan, flinch or grasp) to painful stimuli due to diminished 1 level of consciousness or sedation. OR, limited ability to feel pain over most of body surface. 2 Very Limited: Responds to only painful stimuli. Cannot communicate discomfort except by moaning or restlessness; OR has sensory impairment that limits the ability to feel pain or discomfort over half of body. Slightly Limited: Responds to verbal commands, but cannot always communicate discomfort or need to be turned; OR, has sensory impairment that limits the ability to feel pain or discomfort in one or two extremities. 3 No Impairment: Responds to verbal commands. Has no sensory deficit that would limit ability to feel or communicate pain or discomfort 4


Moisture Constantly moist: skin is kept moist almost constantly by perspiration, urine, drainage etc. Dampness is detected every time patient is moved or turned. 1


Very moist: Skin is often, but not always, moist. Linen must be changed at least every 8 hours. 2 Occasionally moist: Skin is occasionally moist, requiring linen change every 12 hours. 3 Rarely moist: Skin is usually dry, routine diaper changes; linen only requires changing every 24 hours. 4

Friction Shear

Significant problem: spasticity, contractures, itching or agitation leads to almost constant thrashing and friction. 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. 2 Potential problem: Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraint or other devices. Maintains relative good position in chair or bed most of the time but occasionally slides down. 3 No apparent problem: Able to completely lift patient during a position change, moves in bed and in chair independently and has sufficient muscle strength to lift completely during move. Maintains good position in bed or chair at all times. 4


Very poor: NPO and/or maintained on clear fluids, or IVs for more than 5 days OR albumin < 2.5 mg/dl OR never eats a complete meal. Rarely eats more than half of any food offered. Protein intake includes only 2 servings of meat or dairy products per day. Takes fluids poorly. Does not take a liquid dietary supplement. 1 Inadequate: Is on a liquid diet or tube feedings/TPN, which provide inadequate calories and minerals for age OR albumin<3mg/dl OR rarely eats a complete meal and generally eats only half of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. 2 Adequate: Is on tube feedings or TPN, which provides adequate calories and minerals for age OR eats over half of most meals. Eats a total of 4 servings of protein each day. Occasionally eats between meals. Does not require supplementation. 3 Excellent:: Is on a normal diet providing adequate calories for age. For example, 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. 4

Tissue perfusion & oxygenation

Extremely compromised: Hypotensive (MAP<50mmHg; <40 in newborn) or the patient does not physiologicvally tolerate position changes. 1 Compromised: Normotensive oxygen saturation may be <95%; haemoglobin may be <10mg/dl; capillary refill may be> 2 seconds; serum pH is < 7.40. 2 Adequate: Normotensive oxygen saturation may be <95%; haemoglobin may be <10mg/dl; capillary refill may be 2 seconds; serum pH is normal. 3 Excellent:: Normotensive, oxygen saturation >95%; normal haemoglobin; capillary refill <2 seconds 4

Risk score: 16 or less at high risk
© Quigley S & Curley M. 1996, Reprinted with permission, PUPPIES collaborative 2005


Modified Norton Scale



co- Age Additional Diseases
<10 <30 None Undermine




Full Less

Condition Condition
Good Of Fair Alert Apathetic Ambulant WalkHelp

Resistance, fever, diabetes Partly <60 Multiple Scleroses,adiposes None <60 Art c Artery occlusion Very Bad Stupor Poor Confused

ChairBound Stupor


Not 4 3
Risk for pressure ulcers According to modified Norton-Scale: low (25 - 24 points) high (18 - 14 points) medium (23 - 19 points) very high (13 - 9 points)

Slightly Limited Occasional Very Limited Immobile

Usually Urine 2 Doubly 1



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