Abstract
The purpose of this study was to determine the relationship between the scores of Braden scale and pressure ulcer development among critically ill patients. All patients who admitted to intensive care unit (ICU) in 3 months (during July–October 2010) were surveyed with Braden scale. Patients who gained higher score of Braden scale were at lower risk for pressure ulcer development compared with the other patients. Braden scale is a useful tool for predicting pressure ulcer development in trauma ICU patients. Also, factors such as age and level of consciousness may influence pressure ulcer development.
Keywords: Braden scale, Pressure ulcer, Trauma intensive care unit
INTRODUCTION
A pressure ulcer is localised of tissue necrosis that develops when soft tissue is compressed between a prominent bone and the external surface for a long time (1). Factors that cause pressure ulcers include age, dehydration, medication, malnutrition, incontinence, friction and shear (2). Common pressure ulcer points include the occiput, scapula, sacrum, buttocks, ischium, heels and toes (3). A high incidence of pressure ulcers have been considered to be a negative care outcome (4) that markedly affect patients' quality of life, morbidity and mortality (5). Patients in intensive care units (ICUs) are at an increased risk of developing pressure ulcers 4, 5, 6, 7 because they are sedated, ventilated and almost invariably confined to bed for long periods that particularly increase the risk of developing skin breakdown (6).
The development of pressure ulcers in the critically ill patients is a preventable complication (3) and thus many pressure ulcer risk assessment tools such as Braden, Waterlow, Norton and Cubbin–Jackson have been developed 3, 8, 9, 10. Studies reported different results regarding the use of these tools in ICUs. Suriadi et al. (7) compared Braden scale and a multi‐pad pressure evaluator for power of their prediction of pressure ulcer development. They reported no significant difference between the two scales' power (7). Mortenson et al. (11) who reviewed the scales' power and how they predict pressure ulcer development among spinal cord‐injured patients reported that Braden scale has better outcome compared with other scales.
Kim et al. (12) also studied different scales (Braden, Song and Choi, Cubbin and Jackson) to determine and compare their power for prediction of pressure ulcers among surgical ICU patients. They showed that the Cubbin–Jackson scale more effectively predicts pressure ulcer risk compared with the other scales (12). Weststrate et al. (13) reported that Waterlow scale is better than other scales in predicting pressure ulcers in surgical ICU patients. In Iran, Reyhani et al. (14) assessed the incidence of pressure ulcer among cranio‐spinal patients admitted in ICUs. They reported that Braden scale is somehow able to predict pressure ulcer among this group of patients (14). Totally, between the above‐mentioned scales, Braden scale that designed by Bergstrom et al. is the best scale recommended by the US agency for health care policy and research 3, 15. This scale is widely used in hospital setting 3, 15.
In our country, the incidence of pressure ulcer in patients admitted in ICUs reported between 5·2 and 22·5% 14, 16. Iranian critical care nurses use no scale to predict pressure ulcer. They usually assess patients' skin for any sign of pressure ulcer. So they routinely provide the same skin care for patients with different risk of pressure ulcer development. Using some tools that are able to predict the development of pressure ulcer can assist nurses to give proper skin care to the patients who are at the high risk of progression of pressure ulcer. This study, thus, was conducted to examine the relationship between scores of Braden scale and development of pressure ulcer among critically trauma ill patients in south‐east of Iran.
METHODS
This descriptive–prospective study was approved by Kerman medical university and the head of Shahid Bahonar Hospital in Kerman. The study was conducted during July–October 2010 in Shahid Bahonar Hospital in Kerman. This study examined the relationship between pressure ulcer development and Braden scale score among patients admitted in trauma ICU. The relationship between development of pressure ulcer and factors (age, sex as well as level of consciousness) that may influence on pressure ulcer was also assessed. The Braden scale is the most widely used in adult patient population. This scale consists of six subscales including (1) mobility, (2) activity, (3) sensory perception, (4) skin moisture, (5) nutrition state and (6) friction/shear. The items in five subscales scored between 1 and 4. The items in one subscale (fraction/shear) scored between 1 and 3. The total scores ranged from 6 to 23. The lower Braden scale score indicate a higher risk for pressure ulcer development. Different cut‐off scores that are indicative of patients at different risk for pressure ulcer development is suggested as follows: (1) 19–23: no risk, (2) 15–18: mild risk, (3) 13–14: moderate risk, (4) 10–12: high risk and (5) 9 and less: very high risk. Braden scales were filled by researcher and trained staff nurse for all patients who admitted to the ICU and have no pressure ulcer. Patients' skins were assessed three times per day for sign of pressure ulcer development. Patients' level of consciousness was assessed by Glasgow coma scale that routinely used in this ward. Demographic data extracted from patient's medical record. To assess the reliability of translated scale alpha coefficient of internal consistency computed. The alpha coefficient for Braden scale was 0·78. Using the Statistical Package for Social Scientists (SPSS 18.00), data were analysed. Descriptive statistics of the data that were computed included frequencies, means and reliability. To examine the relationship between Braden scale score, age, sex, level of consciousness and pressure ulcer development, Chi‐square test, Pearson correlation test and Independent T‐test were used.
RESULTS
During the 3 months, 82 patients who had no pressure ulcer were admitted. Of them, 68% were men and 32% were women. The mean age of patients was 41·4 years. Mean of Braden score was 13·4 ± 3·5. The mean score of Glasgow coma scale was 10·6 ± 3·7. Of all, 11 (13·4%) patients developed pressure ulcer. Mean age of patients who developed pressure ulcer was 58·6, whereas patients who have not developed pressure ulcer aged 38·7 years. So the age of these two groups was significantly different (P < 0·05). Two groups (with and without pressure ulcer) had different mean of Glasgow coma score (7·7 versus 11·1). This difference was significant (P < 0·05). Pearson correlation test showed a significant correlation between Braden score scale and Glasgow coma score scale (r = 0·823, P < 0·01). The correlation between Glasgow coma score scale and subcategories of Braden score scales was as follows: (1) pressure‐related discomfort (r = 0·873, P < 0·01), (2) degree of physical activity (r = 0·723, P < 0·01), (3) ability to change and control body position (r = 0·644, P < 0·01), (4) friction and Shear (r = 0·582, P < 0·01), (5) degree to which skin is exposed to moisture (r = 0·574, P < 0·01) and (6) usual food intake pattern (r = −0·046, P < 0·01). The rate of pressure ulcer development in both sex was similar (P > 0·05).
Mean score of Braden scale in patients with pressure ulcer was 10·3 and in patients without pressure ulcer was 13·9. Independent T‐test showed that there is a significant difference between Braden scale score and developed pressure ulcer so that the lower Braden scale score, the higher risk for pressure ulcer development (P < 0·05). The results of six subscales of Braden scale was showed in Table 1.
Table 1.
Mean of Braden score in six subgroup
| Subgroup of Braden scale | Patients' status regarding ulcer development | Mean score |
|---|---|---|
| Ability to respond meaningfully to pressure‐related discomfort | With pressure ulcer | 1·72 ± 0·9 |
| Without pressure ulcer | 3·02 ± 1·15 | |
| Degree to which skin is exposed to moisture | With pressure ulcer | 2·63 ± 1·12 |
| Without pressure ulcer | 3·19 ± 0·76 | |
| Degree of physical activity | With pressure ulcer | 1·27 ± 0·63 |
| Without pressure ulcer | 2·16 ± 0·94 | |
| Ability to change and control body position | With pressure ulcer | 1·09 ± 0·3 |
| Without pressure ulcer | 1·6 ± 0·62 | |
| Usual food intake pattern | With pressure ulcer | 2·63 ± 0·93 |
| Without pressure ulcer | 2·28 ± 0·72 | |
| Friction and shear | With pressure ulcer | 1·09 ± 0·3 |
| Without pressure ulcer | 1·6 ± 0·74 |
DISCUSSION
The purpose of this study was to determine the relationship between score of Braden scale and pressure ulcer development among critically ill patients. According to the findings, patients who gain higher score of Braden scale were at lower risk for pressure ulcer development compared to the other patients. In all subscales but one (nutrition: usual food intake pattern) patients with pressure ulcer gain lower score compared to the patients without pressure ulcer. On the basis of the results, the most significant difference between two groups (with and without pressure ulcer) was found in the subscale of sensory perception (ability to respond meaningfully to pressure‐related discomfort). In this subscale, patients with pressure ulcer gain lower score compared with the patients without pressure ulcer (1·79 ± 0·9 versus 3·02 ± 1·5). Unlikely, Reyhani et al. (14) reported that only a decrease in mobility (ability to change and control body position) and sensory perception (ability to respond meaningfully to pressure‐related discomfort) can cause pressure ulcer. This difference could be related to the type of sample in two studies, in Reyhani's study (14), the sample was cranio‐spinal trauma patients who had no activity because of their critical clinical situation. Therefore, in thesubscale of ‘degree of physical activity’ all patients obtained the lowest score. In this study, some patients were able to have activity and thus they could obtain higher score in subscale of ‘degree of physical activity’ compared with those who had no activity. In Reyhani's study (14), moisture was not found as a risk factor for pressure ulcer development, which is inconsistent with the finding of this study. In ICU patients, one of the most causes of moisture is urinary incontinency. Patients in Reyhani et al. (14) study were cranio‐spinal and had indwelling catheter, so they less suffered from urinary incontinency compared with the patient in this study. Totally, the results of this study indicted that Braden scale could be a good predictor tool for pressure ulcer development among critically ill trauma patients. Suriadi et al. (7) in Japan examined the utility of two instruments (the Braden scale and a multi‐pad pressure evaluator) for predicting pressure ulcer development and reported that Braden scale can be a good scale for predicting pressure ulcer development among critically ill patients. Nascimento et al. (17) in 2009 reported that Braden scale is an appropriate tool to use in critically ill patients. In contrast, Cho et al. (18) in South Korea reported that Braden scale is not suitable for prediction of pressure ulcer development in ICUs. This difference can be related to differences between these two studies in three aspects. Cho et al.'s (18) study design is retrospective, whereas this study is prospective. The other difference of two studies is related to the setting within which they were conducted. Cho et al. (18) assessed surgical ICU patients, whereas this study was carried out in trauma ICU patients. In the study by Cho et al. (18), there are some inclusion criteria such as age (higher than 18 years), which are different from those in this study. According to the results, risk of pressure ulcer development in the aged was more than that among younger patients. Reyhani et al. (14) also reported that age correlated with the development of pressure ulcer. Older patients compared with the younger ones have more risk factor for development of pressure ulcer. Impairments in mobility, nutrition, skin health as well as incontinence among older patients may increase the rate of pressure ulcer development (19). Findings also showed significant correlation between Glasgow coma scale score and all subcategories of Braden score scale except nutrition subscale. The most significant correlation was found between Glasgow coma score scale and subscale of pressure‐related discomfort. Glasgow coma score indicates the level of consciousness. Glasgow coma score lower than seven considered as coma. One part of Glasgow coma score is motor function. From score 15 of Glasgow coma score scale, score 6 is related to motor function. In Braden scale, three subscales (degree of physical activity, ability to change and control body position, and ability to respond meaningfully to pressure‐related discomfort) influenced by motor function. Patients who have lower level of consciousness have lower control in urination and are not able to change their position. These may increase the rate of pressure ulcer development among patients with low Glasgow coma score scale. The results also showed that risk of pressure ulcer development among patients with lower Glasgow coma score scale is more than that among patients with higher Glasgow coma score. Decreasing level of consciousness may cause impairment of perception of pressure, activity as well as mobility and consequently increase the risk of pressure ulcer development among critically ill patients with low Glasgow coma score. So Glasgow coma scale should be considered in patients who are at a risk of pressure ulcer, especially critically ill patients. This item can be used for pressure ulcer scale development among critically ill patients.
CONCLUSION
Our findings indicate that Braden scale is a useful tool for predicting pressure ulcer development in trauma ICU patients. The results also showed that factors such as age and level of consciousness may influence pressure ulcer development. These factors do not exist in Braden scale, so such factors should be considered, while predicting pressure ulcer development. Moreover, oxygenation and perfusion situations that are not exist in Braden score scale may also affect pressure ulcer development. So these two factors should be considered in assessment of patients admitted in ICUs. Using Braden Q scale that has these two factors is (oxygenation and perfusion) suggested. Further studies suggest predicting pressure ulcer development among patients who are at high risk for pressure ulcer such as the ones admitted in emergency department and operation room (20). Other scales such as Waterlow scale, Norton scale and Cubbin–Jackson scale are also suggested to be used in order to predict pressure ulcer development among this group of patients. Using one of these scales strongly suggests to the nurses whose patients are at the high risk of pressure ulcer development in order to improve quality of care in trauma ICUs.
REFERENCES
- 1. Potter P, Perry AG. Fundamentals of Nursing, 5th edn. Sidney: Elsevier, 2005:1450–54. [Google Scholar]
- 2. Woodrow Ph. Intensive Care Nursing a Framework for Practice, 2nd edn. Milton Park: Rutledge, 2006:115–16. [Google Scholar]
- 3. Morton PG, Fontaine DK. Critical Care a Holistic Approach, 9th edn. Philadelphia: Lippincott Williams Wilkins, 2009:1336. [Google Scholar]
- 4. Fernandes ML, Caliri MHL, Hass VJ. The effect of educative intervention on pressure ulcer prevention knowledge of nursing professionals. Acta Paul Enferm 2008;21:305–11. [Google Scholar]
- 5. Elliott R, Mckinley SH, Fox V. Quality improvement program to reduce the prevalence of pressure ulcers in an intensive care units. Am J Crit Care 2008;17:328–34. [PubMed] [Google Scholar]
- 6. Keller BP, Van Ramsshorst JB, Van Der Verken C. Pressure ulcers in intensive care patients: a review of risks and prevention. Intensive Care Med 2002;28:1379–88. [DOI] [PubMed] [Google Scholar]
- 7. Suriadi SH, Sugama J, Thighpen B, Kitagava A, Kinosita S, Murayama SH. A new instrument for predicting pressure risk in an intensive care unit. J Tissue Viability 2006;16:2–26. [DOI] [PubMed] [Google Scholar]
- 8. Anders J, Heinemann A, Leffmann C, Leutenegger M, Pröfener F, Renteln‐Kruse W. Decubitus ulcers: pathophysiology and primary prevention. Dtsch Arztebl Int 2010;107:371–82. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Kaitani T, Tokunaga K, Matsui N, Sanada H. Risk factors related to the development of pressure ulcers in the critical care setting. J Clin Nurs 2010;19:414–21. [DOI] [PubMed] [Google Scholar]
- 10. Lindgren M, Unosson M, Krantz AM, Ek AC. A risk assessment scale for the prediction of pressure sore development: reliability and validity. J Adv Nurs 2002;38:190–99. [DOI] [PubMed] [Google Scholar]
- 11. Mortenson WB, Miller VC. A review of scales for assessing the risk of developing a pressure ulcer in individuals with SCI. Spinal Cord 2008;46:168–75. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Kim EK, Lee SM, Lee E, Eom MR. Comparison of the predictive validity among pressure ulcer risk assessment scales for surgical ICU patients. Aust J Adv Nurs 2008;26:87–94. [Google Scholar]
- 13. Weststrta JTM, Hop WCG, Albers AGJ, Vreeling AWJ, Bruining HA. The clinical relevance of the waterlow pressure sore risk scale in the ICU. Intensive Care Med 1998;24:815–20. [DOI] [PubMed] [Google Scholar]
- 14. Reyhani H, Haghiri A. Determination of bed sore risk factors in craniospainal trauma patient in intensive care unit. Arak J Med 2006;10:79–84. [Google Scholar]
- 15. Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden scale for predicting pressure sore risk. Nurs Res 1987;3:205–10. [PubMed] [Google Scholar]
- 16. Ahmadi Nejad M, Rafiei H. Pressure ulcer incidence in intensive care unit patients in Bahonar Hospital, Kerman. J Iran Soc Anaesthesiol Intensive Care 2011;57:10–6. [Google Scholar]
- 17. Silva EWNL, Araujo RA, Oliveira EC, Falcao VTLF. Applicability of a pressure ulcers protocol in intensive care unit. Rev Bras Ter Intensiva 2010;22:175–85. [PubMed] [Google Scholar]
- 18. Cho I, Noh M. Braden scale: evaluation of clinical usefulness in an intensive care unit. J Adv Nurs 2010;66:293–302. [DOI] [PubMed] [Google Scholar]
- 19. Campbell KE. A new model to identify shared risk factors for pressure ulcers and frailty in older adults. Rehabil Nurs 2009;34:242–9. [DOI] [PubMed] [Google Scholar]
- 20. Iranmanesh S, Rafiei H, Ameri GF. Critical care nurses' knowledge about pressure ulcer in southeast of Iran. Int Wound J 2011. doi: 10.1111/ j.1742‐481X.2011.00817.x. [DOI] [PMC free article] [PubMed] [Google Scholar]