The Use of the Modified Norton Scale in Nursing-Home Patients

Patients in three nursing-home wards in Sweden were in 1991 assessed by the Modified Norton Scale (MNS). Of the 71 patients, 38 (49%) were considered to be at risk of developing pressure sores. Six of the patients had a total of eight pressure sores. Five sores were assessed as stage II, two sores as stage III and one sore as stage IV. Only two of the six patients with pressure sores had any preventive equipment in their beds. The nursing and medical documentation of the existing pressure sores was not satisfactory. Individual programs for skin care and routine assessment with a pressure sore prediction instrument, such as the MNS, would serve the dual purpose of directing the relevant measures to the patient groups at the greatest risk and would aid in assessing the efficacy of pressure sore treatment strategies.     

A clinical trial of the Braden Scale for Predicting Pressure Sore Risk

The purpose of this article was to describe the protocol by which predictive instruments can be tested for validity and to evaluate the usefulness of an instrument for predicting pressure sore risk in an AICU. The Braden Scale for Predicting Pressure Sore Risk was described. Methods for measuring predictive validity and for calculating sensitivity, specificity, and per cent predictive value of positive and negative tests were discussed. Sixty consecutively admitted AICU patients who were pressure sore free were rated for pressure sore risk within 24 to 72 hours after admission. The skin condition of each patient was systematically assessed every 2 days. Twenty-four subjects developed pressure sores during the study period. The critical cut-off point at which the patient could be judged to be at risk for pressure sore formation was a Braden Scale score equal to or less than 16. The sensitivity and specificity of the scale at this score were 83 to 64 per cent, respectively. The per cent predictive value of a positive and negative test were 61 and 85 per cent, respectively. The Braden Scale compared favorably with the Norton Scale in respect to sensitivity. The specificity, or the tendency of a scale to overpredict, was greater for the Norton than for the Braden Scale. The Norton Scale overpredicted by 64 per cent, whereas the Braden Scale overpredicted by 36 per cent. This difference may be important clinically if all patients who were judged to be at risk received additional nursing care or protective devices. A greater number of patients may receive unnecessary and expensive treatments using the Norton Scale.     

两种压疮危险评估表预测效果的比较研究

[目的]测量并比较Waterlow压疮危险评估表和Braden修订版压疮危险评估表的预测效果。[方法]分别用两种评估表对332例病人进行评分,分析不同临界值时敏感性、特异性、阳性预测价值、阴性预测价值。[结果]Braden修订版压疮危险评估表以19分为临界值、Waterlow压疮危险评估表以15分为临界值时敏感性、特异性、阳性预测价值、阴性预测价值等指标间能达到较好的平衡,且Braden修订版压疮危险评估表各指标均大于Waterlow压疮危险评估表;Braden修订版压疮危险评估表的ROC曲线下面积略高于Waterlow压疮危险评估表。[结论]Braden修订版压疮危险评估表和Waterlow压疮危险评估表都有较好的预测效果,尤其以Braden修订版效果更优。     

Assessment and evaluation of pressure sores

Pressure sore prevention is the desired goal to maintain skin integrity. It is a challenging nursing responsibility. The process of pressure sore prevention requires skilled nursing assessment of the integumentary system and knowledge of risk factors, as well as an ongoing evaluation plan to monitor incidence and the efficacy of nursing care. Pressure sore assessment is greatly aided by the availability of several research-based instruments. Assessment instruments grounded in research are rather unique because few nursing problems, other than pressure sores, have such instruments available. Further testing of the predictive validity of risk factors is needed even though instruments have already proved valuable in delineating high-risk patients. Well-designed programs of process and outcome evaluation can result in lower incidence rates and reduced severity of pressure sores. Assessment and evaluation are essential to quality nursing care.     

ICU病人压疮危险因素预测量表的系统性回顾(英文)

[目的]本研究旨在描述及确定用于ICU病人最有效的压疮危险因素预测量表。[方法]采用系统性文献回顾方法全面检索1996年—2010年相关文献,数据库包括Medline,CINAHL,Journals@Ovid,Science Direct及中文CAJ。共检出有效研究论文11篇,8篇英文,3篇中文;分析、比较和检视4个常用于ICU病人的压疮危险因素预测量表的敏感性、特异性、阳性预测值、阴性预测值以及各自最佳临界值。[结果]Braden量表为最常用于ICU病人压疮危险因素预测量表,但临界值设定各异;方差分析结果4个量表的4项预测指标之间无统计学意义。Cubbin&Jackson量表的敏感性、阳性预测值和阴性预测值均高于其他3个量表。[结论]虽然Braden量表在国内外均较为常用,但Cubbin&Jackson量表是专门为ICU病人而设置,有较好的预测能力及较固定的临界值,但需要在中国人群中作进一步的验证。     

Immobility--a major risk factor for development of pressure ulcers among adult hospitalized patients: a prospective study

OBJECTIVE: To identify risk factors associated with pressure ulcer development among adult hospitalized medical and surgical patients. DESIGN: A prospective comparative study including 530 adult patients from medical and surgical wards. Registered Nurses made the data collection on admission and once a week for up to 12 weeks. The risk assessment scale used was the Risk Assessment Pressure Sore (RAPS) scale, including the following variables; general physical condition, activity, mobility, moisture, food intake, fluid intake, sensory perception, friction and shear, body temperature and serum albumin. RESULTS: Sixty-two (11.7%) patients developed 85 pressure ulcers. The most common pressure ulcer was that of nonblanchable erythema. Patients who developed pressure ulcers were significantly older, hospitalized for a longer time, had lower scores on the total RAPS scale, had lower weight and lower diastolic blood pressure than nonpressure ulcer patients did. In the multiple logistic regression analyses using variables included in the RAPS scale immobility emerged as a strong risk factor. When adding remaining significant variables in the analyses, mobility, time of hospitalization, age, surgical treatment and weight were found to be risk factors for pressure ulcer development. CONCLUSION: It is confirmed that immobility is a risk factor of major importance for pressure ulcer development among adult hospitalized patients. The results also indicate that the RAPS scale may be useful for prediction of pressure ulcer development in clinical practice.     

非长期卧床患者发生压疮原因分析及对策

目的总结分析临床非长期卧床患者被动发现压疮的原因,并提出针对性对策。方法回顾性分析2003年4月-2007年8月在本院住院的17例非卧床发生压疮患者的临床资料,应用Norton量表对压疮进行评分,分析发生压疮的原因。结果Norton量表评分轻度危险11例、中度危险5例、重度危险1例,通过局部清创、全身营养等支持治疗和护理,除1例患者病情恶化死亡外,其他患者压疮均得到有效控制或治愈。结论加强压疮相关知识培训,以《压疮危险因素评估表》为依据,对患者做好连续评估和分期护理,重视特殊部位皮肤交接班,可以及时、主动发现压疮,积极干预,及时控制患者压疮的发展,减少患者的痛苦。     

The clinical relevance of the waterlow pressure sore risk scale in the ICU

Objective: To evaluate whether the Waterlow pressure sore risk (PSR) scale has prognostic significance for intensive care patients. Design: A prospective study. Setting: The surgical intensive care unit (ICU) of the University Hospital Rotterdam. Patients: Data were evaluated from 594 patients who had been admitted to the ICU during the year 1994. Methods and results: Each patient was assessed daily with respect to their Waterlow PSR score and the development of pressure sores in the sacral region. Actuarial statistical methods were used to analyse the predictive value of the risk score. When a patient had a Waterlow PSR score > 25 on admission, the risk of developing a pressure sore was significantly increased compared to patients with a PSR score < 25. After admission, the daily Waterlow PSR scores obtained were significantly associated with the risk of developing a pressure sore. For each additional point this risk increased by 23 % (95 % confidence interval 17 to 28 %). Conclusions: The Waterlow PSR scale provides the medical and nursing staff at an early stage with reliable information about the risk patients have in developing a pressure sore. Received: 8 August 1997 Accepted: 24 April 1998     

Pressure sores in intensive care: defining their incidence and associated factors and assessing the utility of two pressure sore risk assessment tools.

Patients in intensive care units (ICU) are at high risk of developing pressure sores and the use of pressure sore risk tools has been advocated as a means of identifying patients at risk. A prospective multi-site observational study was conducted to define the incidence of pressure sores, assess two pressure sore risk scales and to define risk factors relevant to intensive care. Patients (n = 534) were assessed for the presence of pressure sores. The Waterlow and Jackson/Cubbin risk scales were completed each day for 314 and 188 of these patients respectively. A total of 75 pressure sores were recorded. Of these, 34 were present on admission. Of the remaining 41, 16 were classified as Grade 1 and 24 as Grade 2 sores. The pressure sore (PS) incidence was 5.2 per cent. Expressed as PS/1000 patient days there were 18.48 pressure sores per 1000 patient days. The ability of the risk scores to predict pressure sores was tested using a Receiver Operating Characteristic (ROC) analysis. The association of risk score with pressure sores was analysed using a survival function (Kaplan Meier) and variables compared using a logrank test (Mantel-Cox). Factors associated with pressure sore occurrence were developed and tested using a survival regression model. Both risk scales were poor predictors of pressure sores (ROC curve area approximately 70 per cent for both). The factors, coma/unresponsiveness/paralysed & sedated and cardiovascular instability were significantly associated with pressure sores with relative risks of 4.2 and 2.5 respectively. Risk increased as a function of time such that the cumulative risk was 50 per cent at 20 days.     

An investigation into the use of serum albumin in pressure sore prediction

OBJECTIVES: To ascertain the relevance of serum albumin and serum sodium as predictors of pressure sores in addition to the Waterlow score. DESIGN: Observational study of patients at risk of developing decubitus ulcers. SETTING: Staffordshire, in the midlands of the United Kingdom. PARTICIPANTS: 773 elderly hospital in-patients of a district general hospital. MEASUREMENTS: Waterlow scores and serum albumin and sodium. Development of a pressure sore. RESULTS: Logistic regression analysis of serum albumin, serum sodium and the Waterlow score showed the Waterlow score and serum albumin were significant predictors of pressure sores. CONCLUSIONS: Serum albumin may, in this patient group (in-patients over 64 years of age), be a useful predictor of pressure sore occurrence, though further work is needed to establish whether this is the case. Risk assessment of pressure sores can possibly be improved by adding serum albumin to one of the pre-existing tools such as the Waterlow score.     

压疮危险因素评估表预测不同患者群体压疮发生的研究

目的比较压疮危险因素评估表（Norton ulcer risk assessment scale,以下简称Norton量表）对不同年龄组及不同病区患者压疮的预测效果。方法运用Norton量表对内外科住院患者进行连续评估,计算量表对不同患者群体预测的灵敏度、特异性、预测值。结果 Norton量表对老年患者灵敏度96.96%、特异性87.68%、阳性预测值22.96%,阴性预测值99.87%;对中青年患者灵敏度97.37%、特异性96.73%、阳性预测值12.05%、阴性预测值99.98%,Norton量表对老年患者及中青年患者压疮预测均具有较高的灵敏度和特异性。Norton量表对内科、外科及不同病区患者均具有较高的预测灵敏度;对神经外科、ICU患者预测特异性较低。结论 Norton量表对不同年龄组和不同病区患者皆具有较好的预测效果,内外科各病区可以统一使用Norton量表对患者进行压疮高危筛查和评估。     

手术患者压力性损伤风险评估工具的多中心测评研究

目的：检验手术患者压力性损伤风险评估工具在多中心临床应用的信效度及预测能力,并与Waterlow量表进行临床应用效果的对比。方法：采用配额抽样方法,选取2020年7月至12月天津市4所三级甲等医院530例全麻手术患者作为研究对象,对手术患者压力性损伤风险评估工具进行信效度检测,并与Waterlow量表进行压力性损伤风险预测能力的比较。结果：手术患者压力性损伤风险评估工具在手术前、手术后2个阶段的Cronbach’s α系数分别为0.809、0.804;平均量表水平的内容效度指数为0.905;旋转变换累积方差贡献率显示,12个条目均在8%左右,有较强的稳定性,特征值>1的条目累积方差贡献率为75.5%;其术前、术后ROC曲线下面积分别为0.722、0.732;Waterlow量表ROC曲线下面积为0.574。结论：手术患者压力性损伤风险评估工具有较好的信效度和预测能力,可有效判断手术患者压力性损伤风险程度,具有手术患者普适性特点,为手术室压力性损伤同质化预防管理奠定了基础。     

Logistic Regression Analysis and Nursing Interventions for High-risk Factors for Pressure Sores in Patients in a Surgical Intensive Care Unit

Objective:To investigate the risk factors related to the development of pressure sores in critically ill surgical patients and to establish a basis for the formulation of effective precautions.Methods:A questionnaire regarding the factors for pressure sores in critically ill surgical patients was created using a case control study with reference to the pertinent literature.After being examined and validated by experts,the questionnaire was used to collect data about critically ill surgical patients in a grade A tertiary hospital.Among the 47 patients enrolled into the study,the 14 who developed nosocomial pressure sores were allocated to the pressure sore group,and the remaining33 patients who met the inclusion criteria and did not exhibit pressure sores were allocated to the control group.Univariate and multivariate logistic regression analyses were employed to examine the differences in22 indicators between the two groups in an attempt to identify the risk factors for pressure sores.Results:According to the univariate analyses,the maximum value of lactic acid in the arterial blood,the number of days of norepinephrine use,the number of days of mechanical ventilation,the number of days of blood purification,and the number of days of bowel incontinence were statistically greater in the pressure sore group than in the control group(P0.05).The multivariate logistic regression analysis revealed that the number of days of norepinephrine use and the level of lactic acid in the arterial blood were high risk-factors for pressure sores(P0.05).Conclusions:The best method for preventing and control pressure sores in surgical critically ill patients is to strongly emphasize the duration of the critical status and to give special attention to patients in a continuous state of shock.The adoption of measures specific to high-risk patient groups and risk factors,including the active control of primary diseases and the application of decompression measures during the treatment of the patients,are helpful for improving the quality of care in the prevention and control of pressure sores in critically ill patients.     

压疮管理系列表格的设计与应用

目的 探讨压疮管理系列表格的实用性及在提高护士高危压疮和院外带入压疮上报符合率、压疮护理记录书写合格率中的作用和效果.方法 将2010年上报的高危及院外带入压疮433例作为观察组,将2009年上报的高危及院外带入压疮205例作为对照组.设计和应用压疮管理系列表格,包括高危压疮评估表、高危压疮申报单、院外压疮呈报表、压疮防治护理记录单等4种压疮管理表格,采用表格、图示、说明等辅助设计,并应用于观察组中,比较2组各项指标.结果 与对照组相比,观察组的高危压疮及院外带入压疮上报符合率、压疮护理记录书写合格率、压疮治愈和好转率提高,高危压疮发生数显著减少.结论 压疮管理系列表格有助于护士准确评估高危压疮及院外带入压疮,有助于提高压疮治愈、好转率及护士书写压疮护理记录的质量.

Abstract：

Objective To explore the practicability of the pressure sore management forms and its effect on improving the nurses' reported compliance rates on high-risk pressure sores and external pressure sores and the passing rate of nursing records. Methods With aided designs as forms, icons and notes,making a comparative analysis on high-risk pressure sores and external pressure sore between 433 cases in 2010(the observation group) and 205 cases in 2009(the control group). Designing and applying the pressure sore management forms, including four kinds of forms: the high-risk assessment form, high-risk pressure sores declaration sheet, the external pressure sore report form, pressure sore prevention and care record sheet, then applied them in the observation group. Results Compared with the control group, all aspects like the compliance rates of nurses' reports on high-risk pressure sores and external pressure sore, the passing rate of nursing records, the healing and improvement rates were obviously increased, the occurrence rate of high-risk pressure sores decreased. Conclusions The pressure sore management forms can help nurses for accurate assessing high-risk pressure sores and external pressure sores, also can help to increase the healing and improvement rate and to enhance the quality of nursing records.     

The surveillance system of decubital lesions of the University Polyclinic in Udine: results of an incidence study

A retrospective study of the incidence of pressure sores was one of the principal component of the ad hoc program of surveillance, prevention and treatment of pressure sores started in 1996 at University Hospital of Udine. Data were collected from the nursing records of patients defined at risk according to the Waterlow scale and admitted during 1998-99. Aims of the study were to quantify the number of patients who developed a pressure sore while in hospital and their risk level; stage of the lesions; to qualify the main risk factors and the management strategies adopted (i.e. mattresses, medications). Overall, 151 subjects (20.7% of those recruited) developed a pressure sore the greatest majority (96%) were classified as transient and reactive redness or superficial sore, while 14 patients (4%) developed a severe sore. For 50.4% of the lesions a regression to a lower risk level or healing were documented.     

Validity of pressure ulcer risk assessment scales; Cubbin and Jackson, Braden, and Douglas scale

This study was to compare the validity of three pressure ulcer risk tools: Cubbin and Jackson, Braden, and Douglas scales. Data were collected three times per week from 48 to 72 h after admission based on the three pressure ulcer risk assessment scales and skin assessment tool developed by the Panel for the Prediction and Prevention of Pressure Ulcers (1994) from 112 intensive care unit (ICU) patients in a educational hospital Ulsan, Korea during December 11, 2000 to February 10, 2001. When a patient developed a pressure ulcer at the time of assessment, the patient was classified into 'pressure ulcer group', and when patients did not have a pressure ulcer until they died, moved to other wards or were discharged from the hospital, they were classified into 'not pressure ulcer group'. Four indices of validity and area under the curves (AUC) of receiver operating characteristic (ROC) were calculated. Based on the cut-off point presented by the developer, sensitivity, specificity, positive predictive value, negative predictive value were as follows: Cubbin and Jackson scale: 89%, 61%, 51%, 92%, respectively, Braden scale: 97%, 26%, 37%, 95%, respectively, and Douglas scale: 100%, 18%, 34%, 100%, respectively. AUCs of ROC curve were 0.826 for Cubbin and Jackson, 0.707 for Braden, and 0.791 for Douglas. Overall, the Cubbin and Jackson scale showed the best validity among scales tested and we recommended it for this ICU.     

An analysis of epidural related pressure sores in a specific patient population

The objective of this study was to investigate the relationship between post-operative epidural analgesia and incidence of heel pressure sores. The study sample consisted of 53 men and women over the age of 20 years who had major abdominal surgery (mean age 69 years). The main outcome measure was the number of patients who developed any degree of heel sore in the post-operative period. Pressure sore risk assessments were completed by the general surgical nurses with grade of risk recorded. Twenty-one percent of patients in the study developed pressure changes on the skin of their heels; 5.7% developed changes of Grade 2 or worse. Only 10 patients (18.9%) were scored as being at high risk of pressure sores post-operatively. Fifteen (28.3%) patients had no pressure sore risk assessment carried out post-operatively. Ward staff failed to recognise that their patients had been placed at high risk by the use of epidural analgesia post-operatively.     

Waterlow计分表在神经内科预防压疮中的应用

目的评价Waterlow计分表对神经内科卧床患者压疮的预测效果。方法应用Waterlow计分表作为评估工具,通过对新入神经内科患者进行评估,根据分值采用不同的预防措施。结果 2014年神经内科压疮高危患者上报率显著增加(P0.01),高危患者院内压疮发生率显著下降(P0.01)。结论 Waterlow计分表应用于神经内科临床预防压疮具有可靠性、有效性。     

Investigating the reliability and validity of the waterlow risk assessment scale: a literature review

The aim of this review was to examine health literature on the reliability and validity of the Waterlow pressure sore assessment scale. A systematic review of published studies relating to the topic was conducted and literature was examined for its relevancy to the topic under investigation. Findings suggest that despite the availability of over 40 assessment tools, the Waterlow assessment scale is the most frequently used by health care staff. Research suggests that the Waterlow Scale is an unreliable method of assessing individuals at risk of pressure sore development with all studies indicating a poor interrater reliability status. Its validity has also been criticized because of its high-sensitivity but low-specificity levels.