The current climate of fiscal retrenchment and escalating health care costs mandates that nurses closely scrutinize the areas of professional practice in which they exert a powerful influence. One such challenge is the assessment, prevention, and management of pressure ulcers.
Appropriate management of patients at risk for pressure ulcer development begins with a thorough and clinically sound assessment. The financial expenditure involved in instituting an assessment and prevention program may prove cost-effective when one considers that the treatment of a single ulcer is estimated to cost between $5,000 and $34,000 (Blom, 1985). Pressure ulcers represent a significant cause of human suffering, destined to increase in prevalence as the number of fragile elderly and survivors of serious trauma grow (National Pressure Ulcer Advisory Panel, 1989).
The plethora of articles in nursing journals regarding various aspects of pressure ulcer management is testimony to the ubiquity of this problem. Impaired skin integrity was found to be among the five most common nursing diagnoses for elderly patients and long-term care residents (Hardy, 1989). Pressure ulcer prevention and treatment has been recognized as a clinical research priority among practicing nurses (Brower, 1985; Dennis, 1989).
The initial step in any prevention strategy is the identification of those clients at risk. Assessment tools have gained increasing popularity as a means to implement efficient risk identification. To be functional, assessment tools should meet a number of criteria (Larson, 1986). According to Larson, assessment tools should address an important problem; identify when preventive measures might be useful; and be simple, convenient, reliable and cost-effective. Pressure ulcer risk assessment tools have the potential to satisfy each of these conditions and contribute to quality nursing care as a result.
Variables Included in Risk Assessment Tools
The formalization of the concept of pressure ulcer risk assessment is largely attributable to Norton, ExtonSmith, and McLaren with the publication of the Norton Scale (Norton, 1962). This tool allowed pressure ulcer risk to be quantified using a numerical scoring system based on five criteria: physical condition, mental state, activity, mobility, and incontinence.
As the Norton Scale became more widely used, certain shortcomings became apparent. Because the scale was developed for research with the elderly, some authors questioned its applicability to other populations (Bliss, 1982; Goldstone, 1982). Others criticized the Norton Scale on the basis of the crudeness of its categories and its lack of attention to the roles of nutrition and pain in pressure ulcer development (Jones, 1986).
Reliability and Validity of the Norton and Braden Scales
Gosnell adapted the Norton Scale to include nutritional status and delete physical status. Research using the revised scale indicated that mobility, activity, nutrition, and mental status were significant variables in pressure ulcer development; incontinence was found not to be significant (Gosnell, 1973).
The Gosnell adaptation of the Norton Scale was further tested by Pajk and colleagues (1986) in a study of 208 hospitalized patients. The results indicated that risk factor variables in rank order were altered nutritional status, impaired activity, impaired mobility, incontinence, and altered mental status. All variables were found to be strongly associated with pressure ulcer formation.
The prominent role of nutrition in both studies suggests that the omission of this important variable limits the usefulness of pressure ulcer assessment tools that do not include nutrition. Less clear is the impact of incontinence on pressure ulcer development.
A recently published assessment tool, the Braden Scale (Bergstrom, 1987), incorporates factors long recognized to be highly influential in pressure ulcer development. Moisture, friction, and shear are generally accepted as key contributors to impaired skin integrity (Crow, 1988; Shannon, 1984; Sklar, 1984; Wienke, 1987). The emphasis on these variables within the Braden Scale make this risk assessment tool a serious rival to the omnipresent Norton Scale.
Table 1 examines a number of pressure ulcer risk management tools documented in the nursing literature in terms of variables. The more recent assessment tools appear to be more likely to include nutrition and less likely to include activity and physical status as predictive variables.
It is at this point that careful examination of research findings becomes critical. If cost-effectiveness and clinical efficacy are to be considered, both the reliability and the predictive validity of the instruments must be carefully scrutinized. The tool of choice would allow nurses to accurately predict the patients at risk for developing pressure sores, but not overpredict and thus waste precious resources. Preventive measures could then be appropriately implemented for those who, in fact, require them.
Table 2 compares the reliability and validity of the Norton and Braden Scales at various scores (data is unavailable for the remaining scales). Sensitivity refers to the proportion of high risk subjects who develop a pressure ulcer when they were predicted to do so. Specificity measures the proportion of those considered at low risk by the tool who did not develop a pressure ulcer (Bergstrom, 1987). An ideal instrument would be 100% sensitive and 100% specific.
It is evident that neither the Norton nor the Braden tools can be considered the ideal scale at this time. Although the Braden Scale demonstrates fairly good reliability, no data is available for the Norton Scale. The Braden Scale also compares favorably with the Norton Scale at the critical score values, which is the point in each scale at which preventive resources would be mobilized. Because of variation in both scale construction and study design, however, it is not possible to compare the scales in an empirical manner from the existing data.
Pressure ulcer prevention remains a significant nursing concern worthy of continued study. The wide variety of assessment tools reported in the literature, however, leaves practitioners in a quandary when they must select one for clinical implementation.
The Norton and Braden Scales have thus far received the most empirical attention, although dissimilarities in study design create difficulties in comparison.
It is obvious much work remains to be done. A logical starting point for nurses interested in further pursuing pressure ulcer risk assessment tools would be to design a carefully controlled comparative study of the available scales. Relative reliability and validity could thus be established. Such research would immensely benefit both the recipients of care and the practitioners of nursing. In the meantime, nurses must consciously and knowledgeably make decisions about the risk assessment tool most suitable for their own practice.
- Bergstrom, H., Demuth, PJ., Braden, B. A clinical trial of the Braden Scale for predicting pressure sore risk. Nurs Clin North Am 1987; 22:417-428.
- Bergstrom, N., Braden, B., Laguzza, A., HoIman, V. The Braden Scale for predicting pressure sore risk. Nurs Res 1987; 36:205210.
- Bliss, M.R. Preventing pressure sores. Geriatric Medicine 1982; 12(4):26-28.
- Blom, MJ. Dramatic decrease in decubitus ulcers. Geriatr Nurs 1985; 6:84-87.
- Braden, B., Bergstrom, N. A conceptual schema for the study fo the ediology of pressure sores. Journal of Rehabilitation Nursing 1987; 12(1):8-12, 16.
- Brower, H.T., Crist, M.A. Research priorities in gerontologie nursing for long-term care. Image. The Journal of Professional Nursing 1985; 17(2):22-27.
- Crow, R. The challenge of pressure sores. Nursing Times 1988; 84(38):61,71,78.
- Dennis, K.E., Howes, D.G., Zelauskas, B. Identifying nursing research priorities: A first step in program development. Applied Nursing Research 1989; 2:108-113.
- Goldstone, L.A., Goldstone, J. The Norton score: An early warning on pressure sores? J Adv Nurs 1982; 17:419-426.
- Gosnell, D.G. An assessment tool to identify pressure sores. Nurs Res 1973; 22:55-59.
- Hardy, M.A., Maas, M., Akins, J. The prevalence of nursing diagnoses among elderly and long-term care residents: A descriptive study. In R.M. Carroll-Johnson (Ed.), Classification of nursing diagnoses: Proceedings of the eighth conference. Toronto; CV Mosby Co, 1989.
- Jones, P.G., Millman, A. A three-part system to combat pressure sores. Geriatr Nurs 1986; 7(2):78-81.
- Knoll Pharmaceutical Company. The Knoll Scale of liability to pressure sores. In J. McFarlane, G. Casteldine (Eds.), A guide to the practice of nursing. St. Louis: CV Mosby Co, 1982.
- Larson, E. Evaluating validity of screening tests. Nurs Res 1986; 35:186-189.
- Lowthian, P. Turning clock system to prevent pressure ulcers. Nursing Mirror 1979; 148:30.
- National Pressure Ulcer Advisory Panel. Pressure ulcers prevalence, cost and risk assessment: Consensus development. Decubitus 1989; 2(2):24-28.
- Norton, D., Exton-Smith, A.N., McLaren, R. An investigation of geriatric nursing problems in hospital. London: National Corporation for the Care of Old People, 1962.
- Pajk, M., Craven, G.A., Cameron-Barry, J., Shipps, T, Bennum, N.W. Investigating the problem of pressure sores, journal of Gerontological Nursing 1986; 12:11-16.
- Pritchard, V. Calculating the risk. Nursing Times 1986; 82(8):59-60.
- Shannon, M.L. Five famous fallacies about pressure sores. Nursing84 1984; 14(10):3441.
- Sklar, CG. Pressure ulcer management in the neurologically impaired patient. Journal of Neurosurgical Nursing 1984; 17(l):30-36.
- Warner, U. Pressure sores: A policy for prevention. Nursing Ttmes 1986; 82(16):59-61.
- Waterlow, J. A risk assessment card. Nursing Times 1985; 81(48):48,49,51,55.
- Wienke, VK. Pressure sores: Prevention is the challenge. Orthopaedic Nursing 1987; 6(4):2630.
Variables Included in Risk Assessment Tools
Reliability and Validity of the Norton and Braden Scales