Skin integrity in hospitalized infants and children: a prevalence survey

The purpose of this paper was to describe the spectrum of alterations in skin integrity and skin care needs of hospitalized infants and children. A 1-day skin prevalence audit was conducted in the spring of 2005 in a tertiary care university-affiliated children's hospital. Patient skin was assessed for any alterations. The Braden Q Scale was used to assess patient risk for pressure ulcer development. Alterations in skin integrity included diaper dermatitis, pressure ulcers, intravenous infiltrations, device-related injuries, and epidermal injuries. Many patients required additional skin care, including wound/incision care, ostomy care, and care related to invasive devices. Alterations in skin integrity represent a serious problem in the pediatric inpatient setting. The data presented identify skin integrity challenges in the hospitalized patient and can help guide staff education and resource allocation, encourage evidenced-based management protocols, and serve as a benchmark for similar pediatric facilities.     

Incidence of pressure ulcers in a neurologic intensive care unit

OBJECTIVES: To determine the risk factors for pressure ulceration in an intensive care setting, to evaluate the Braden scale as a predictor of pressure ulcer risk in critically ill patients, and to determine whether pressure ulcers are likely to occur early in the hospital stay. DESIGN: Cohort study of patients with no preexisting ulcers with a 3-month enrollment period. SETTING: The neurologic intensive care unit and the neurologic intermediate unit at a primary care/referral hospital with a level I trauma center. PATIENTS: A total of 186 patients entered the study. INTERVENTION: Within 12 hrs of admittance, initial assessment, photographs, and Braden score were completed. Patients were re-examined every 4 days or at discharge from the unit, whichever came first. MAIN OUTCOME MEASURES: Determining risk factors for pressure ulcers, performing detailed statistical analyses, and testing the usefulness of the Braden score as a predictor of pressure ulcer risk. RESULTS: Twenty-three of 186 patients developed at least one pressure ulcer (incidence = 12.4%) after an average stay of 6.4 days. The Braden scale, which measures six characteristics of skin condition and patient status, proved to be a primary predictor of ulcer development. No ulcers developed in the 69 patients whose Braden score was 16 or higher. The likelihood of developing a pressure sore was predicted mathematically from the Braden score. However, being underweight was a significant and distinct factor in pressure ulcer development. CONCLUSIONS: Pressure ulcers may develop within the first week of hospitalization in the intensive care unit. Patients at risk have Braden scores of < or = 16 and are more likely to be underweight. These results suggest that aggressive preventive care should be focused on those patients with Braden scores of < or = 13 and/or a low body mass index at admission.     

The braden q+p: a pediatric perioperative pressure ulcer risk assessment and intervention tool

Pressure ulcers continue to be a personally and financially expensive complication of surgery and hospitalization. The effects of anesthesia, immobilization during surgery, and use of multiple medical devices all place the surgical patient at high risk for pressure-related skin injury. As part of a comprehensive pressure ulcer prevention initiative, nurses in the cardiac and main ORs at Children's Hospital Boston, Massachusetts, became concerned that current pressure ulcer risk assessment tools did not adequately capture the intense but short-term risk posed in the operating and procedural suites. A team, formed to investigate this matter, developed a tool to guide nursing assessment of patient risk and to plan nursing interventions to prevent pressure ulcers. Results after implementation of the Braden Q+P tool appear to show improvement in preventing pressure ulcers. Increased awareness of pressure ulcer prevention, a hospital focus on skin care, and nursing education about pressure ulcers supported this improvement.     

Assessing predictive validity of the modified Braden scale for prediction of pressure ulcer risk of orthopaedic patients in an acute care setting

Aims and objectives. To assess and compare the predictive validity of the modified Braden and Braden scales and to identify which of the modified Braden subscales are predictive in assessing pressure ulcer risk among orthopaedic patients in an acute care setting. Background. Although the Braden scale has better predictive validity, literature has suggested that it can be used in conjunction with other pressure ulcer risk calculators or that some other subscales be added. To increase the predictive power of the Braden scale, a modified Braden scale by adding body build for height and skin type and excluding nutrition was developed. Design. A prospective cohort study. Method. A total of 197 subjects in a 106‐bed orthopaedic department of an acute care hospital in Hong Kong were assessed for their risk for pressure ulcer development by the modified Braden and Braden scales. Subsequently, daily skin assessment was performed to detect pressure ulcers. Cases were closed when pressure ulcers were detected. Results. Out of 197 subjects, 18 patients (9·1%) developed pressure ulcers. The area under the receiver operating characteristic curve for the modified Braden scale was 0·736 and for the Braden scale was 0·648. The modified Braden cut‐off score of 19 showed the best balance of sensitivity (89%) and specificity (62%). Sensory perception (Beta = ?1·544, OR=0·214, p = 0·016), body build for height (Beta = ?0·755, OR = 0·470, p = 0·030) and skin type (Beta = ?1·527, OR = 0·217, p = 0·002) were significantly predictive of pressure ulcer development. Conclusion. The modified Braden scale is more predictive of pressure ulcer development than the Braden scale. Relevance to clinical practice. The modified Braden scale can be adopted for predicting pressure ulcer development among orthopaedic patients in an acute care setting. Specific nursing interventions should be provided, with special attention paid to orthopaedic patients with impaired sensory perception, poor skin type and abnormal body build for height.     

Braden压疮风险护理记录单在卧床患者中的应用

目的:探讨Braden压疮风险护理记录单在卧床患者中的应用效果。方法:将2009年1月～2010年1月本科收治的卧床患者50例作为对照组,将2010年2月～2011年2月50例卧床患者作为试验组,对照组采用常规的防压疮护理,试验组采用Braden压疮风险护理记录单对卧床患者评估评分后实施防压疮护理,比较两组患者的压疮发生率。结果:试验组患者压疮发生率明显低于对照组(P<0.05)。结论:Braden压疮风险护理记录单的使用能有效降低卧床患者压疮的发生率,保障卧床患者的皮肤安全。     

Skin Integrity in the Pediatric Population: Preventing and Managing Pressure Ulcers

purpose . To summarize clinical and empirical knowledge about pressure ulcers in infants and children and to describe an approach developed at Children's Hospital, Boston, to prevent and manage pressure ulcers
population . Acutely ill children with potential or actual alteration in skin integrity due to pressure ulcers
conclusions . The three-pronged approach for pressure ulcer prevention and management developed by the Skin Care Task Force at the Children's Hospital, Boston, decreases unnecessary variation in practice surrounding the prevention and care of pressure ulcers in acutely ill children.
practice implications . The Skin Care Task Force recommends use of the Braden Q for pediatric risk assessment, a skin care algorithm for prevention of pressure ulcers, and a pressure ulcer algorithm for staging and managing pressure ulcers.     

Braden scale: validity in community-based older adults receiving home health care.

The purpose of this study was to examine the validity of the Braden Scale and optimal frequency of risk reassessment in older adults receiving home health care. Data were collected from the records of 1,711 nonhospice patients aged 60 years or older who did not have pressure ulcers at the beginning of home health care. Patient records were followed forward chronologically to one of two outcomes: pressure ulcer development or pressure ulcer absence (pressure ulcer free when home health services were no longer required, institutionalization, death, or end of study period). After commencement of home health care, 108 subjects developed a stage I-IV pressure ulcer (incidence = 6.3%). A Braden Scale cutoff score of 19 provided the best measure of sensitivity (61%) and specificity (68%). Findings suggest initial assessment of pressure ulcer risk for older adults should begin on entry into home health care, and they indicate the need for weekly reassessments for the first 4 weeks with every other week reassessments thereafter until day 62, dependent on patient condition and the frequency of home visits. Reassessment with each subsequent 62-day recertification period may be sufficient for patients remaining on the active caseload.     

Predicting the risk of pressure ulcers in critically ill patients.

BACKGROUND: Critically ill patients are at high risk for pressure ulcers. OBJECTIVES: To determine the contributions of the Braden subscales in predicting pressure ulcers in critically ill patients and to investigate how often the Braden scale should be completed to assess the risk for pressure ulcers in critically ill patients. METHOD: The Braden scale was used to assess repeatedly 136 adult patients without pressure ulcers in a medical intensive care unit, a surgical intensive care unit, and a noninvasive respiratory care unit, and the patients' skin was inspected routinely for pressure ulcers. RESULTS: A total of 36 pressure ulcers, most commonly on the sacrum or coccyx and the heels (15 stage 1, 20 stage 2, 1 stage 3), developed in 17 patients (12%). In 14 (82%) of the 17, the ulcers developed within 72 hours of admission to the intensive care unit. The risk for pressure ulcers increased as the mean sensory perception (P = .01) and the mean total Braden (P = .046) scores decreased. The mean sensory perception scores obtained at 12 and 36 hours after admission also had a significant relationship to the risk for pressure ulcers (P = .03). CONCLUSIONS: Patients in intensive care units have an increased risk for pressure ulcers. Although waiting until 12 hours after a patient's admission to the intensive care unit to obtain the initial Braden rating may be reasonable (with the second rating obtained 36 hours after admission), additional research is needed before this practice can be recommended.     

手术患者压疮发生率及发生时间和影响因素研究

目的：探讨手术患者压疮发生率、发生时间特点和相关因素,为临床制定应对措施提供依据。方法：按照统一标准在12所综合医院中入选1074例术后患者,预防措施相同,采用“外科压疮风险评估表”收集每例患者术后0～5d基线资料,使用Braden计分量表评估压疮危险。采用Logistic回归分析压疮发生的影响因素。结果：观察期内1074例手术患者中发生11例11处Ⅰ期压疮,发生率1.02%,其中外科监护病房发生率1.95%。多发生在术后1～3d内。压疮发生的影响因素为：手术时间、术后皮肤水肿和使用矫形装置及Braden计分（P〈0.05）。结论：对手术时间≥2h、术后皮肤水肿、使用矫形装置及Braden计分≤16分的患者应作为术后压疮预防的重点对象,但Braden量表对围手术期患者压疮风险的预测作用尚有待于进一步研究。     

Braden评分联合微循环评价指标构建创伤重症患者压力性损伤风险可视化预后模型

目的:基于Braden评分,联合局部皮肤温度和局部组织氧饱和度作为局部微循环指标,构建创伤重症患者压力性损伤风险预后模型,并开发可视化列线图。方法:选取浙江省某三甲医院2020年06月1日至2020年08月31日期间所有进入急诊重症监护室（EICU）的创伤患者,采取Braden量表评估患者压力性损伤发生风险,测量患者骶尾部受压部位皮肤温度与血氧饱和度,作为微循环评价指标。采用多因素Logistic回归构建基于Braden评分联合微循环评价指标的创伤重症患者压力性损伤预后模型及可视化列线图,并与单纯Braden量表构建的预测模型比较。通过计算受试者操作特征曲线下面积判断预测模型区分度。C指数对最佳模型进行内部验证、H-L拟合优度检验、整体鉴别指数观察预测模型效果。结果:本研究共纳入152例患者,其中33例发生压力性损伤,占21.71%。Braden量表联合局部皮肤温度与局部组织氧饱和度后曲线下面积为0.866,模型内部验证C指数为0.847。H-L拟合优度检验结果为8.37, P=0.051,即模型具有良好区分度与一致性。模型整体鉴别指数=0.144, P=0.023。 结论:Braden量表联合局部微循环指标构建创伤重症患者压力性损伤预后模型具有良好区分度与一致性,较单纯Braden量表预测效力提高14.4%,据此构建列线图,能够为临床提供快捷、方便可靠的预测工具。     

Assessment of the accuracy of the CALCULATE scale for pressure injury in critically ill patients

IntroductionPressure injury is damage to the skin and underlying soft tissue that occurs in response to intense and/or prolonged skin pressure. The Braden scale is the most used in health services to assess pressure injury. However, this scale was not specifically developed for critically ill patients. The Critical Care Pressure Ulcer Assessment Tool Made Easy (CALCULATE) scale was developed for patients in intensive care units.ObjectiveThe objective of this study was to compare the accuracy of the CALCULATE scale with that of Braden in predicting the risk of pressure injury in critically ill patients.MethodsThis was a prospective cohort study, involving patients who did not have pressure injury on admission to the intensive care unit of a tertiary hospital in the city of Porto Alegre, Brazil. Data collection took place between January and July 2020 using the Braden and CALCULATE scales, in addition to clinical and sociodemographic variables. Patients were followed up until discharge from the intensive care unit or death.ResultsFifty-one patients were included in the study. Of these, 29 (56.9%) developed pressure injury. To predict pressure injury onset, the areas under the receiver operator characteristic curve of the Braden scale on the first day and the lowest score during the first 3 days were 0.71 (0.56–0.86) and 0.70 (0.53–0.87), respectively. The areas under the receiver operator characteristic curve of the CALCULATE scale on the first day and the highest score during the first 3 days were 0.91 (0.82–0.99) and 0.92 (0.85–1.00), respectively. In the logistic regression analysis, the CALCULATE scale on the first day remained an independent predictor of pressure injury onset after controlling for age and length of stay in the intensive care unit.ConclusionWe found that the CALCULATE scale may be more accurate than the Braden scale as a tool to assess the risk of developing pressure injury in critically ill patients.     

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.     

Using the Braden Q Scale to Predict Pressure Ulcer Risk in pediatric patients

The Braden Q Scale for Predicting Pediatric Pressure Ulcer Risk (Braden Q Scale) is a widely used, valid, and reliable pediatric-specific pressure ulcer risk assessment tool. Since its original publication, requests for clarification on how best to use the tool across the wide spectrum of pediatric patients commonly cared for in health care systems have been received. Common clarifications focus on using the Braden Q Scale as originally designed; specifically, not using untested derivations of the tool, and not using the Braden Q Scale to predict medical device-related pressure damage. The purpose of this article is to provide practical information on how best to use the Braden Q Scale and how to score a pediatric patient's risk for pressure ulcers. Accurate assessment of patient risk for pressure ulcers is the first step in guiding appropriate nursing interventions that prevent pressure ulcers. Patient assessment, scoring, and common clinical scenarios are presented.     

循证护理干预方案在ICU压疮高危患者中的应用

目的探讨循证护理干预方案在ICU压疮预防中的作用。方法将227例Braden评分≤12分的压疮高危患者按照入院的顺序分为对照组102例和观察组125例。对照组采用常规护理方法。观察组进行循证护理干预,予每2h翻身1次,左右30°侧卧位交替进行;平卧位时抬高患者床头不超过30°,足跟处垫软枕;对Braden评分〈7分、颈椎骨折及病情限制翻身的患者必须使用气垫床;在受压皮肤处及可能发生压疮的皮肤区域喷赛肤润;在皮肤受压部位应用康惠尔透明贴;根据患者营养状况给予肠内外营养;保持肛周皮肤干燥。比较2组的压疮发生情况。结果观察组的压疮发生率明显低于对照组,发生时间延迟,压疮严重程度轻。结论在ICU压疮高危患者中应用循证护理干预方案,能体现护理工作的科学性和艺术性,更有效地分配有限的护理资源,减少压疮的发生。     

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.     

The quality of pressure ulcer prediction and prevention in home health care.

The purpose of this study was to assess the quality of pressure ulcer prediction and prevention in home health care. Randomly selected Medicare-certified home care agencies in four midwestern states were surveyed. The overall response rate was 44% (n = 128). Approximately half (57.8%) of the responding agencies assessed all patients for pressure ulcer risk upon admission; another 4.7% assessed only chair or bed-bound patients. Clinical nursing judgment was the most commonly (72%) used method for assessing risk; only 21% of the agencies used a validated tool such as the Braden Scale or the Norton Scale to identify those at risk. Approximately one third of the reporting agencies had prediction and/or prevention policies. Only 18.0% of home health care agencies identified recommended interventions in a pressure ulcer prevention protocol. Findings suggest opportunities for improvement in pressure ulcer prediction and prevention practice in home health care.     

Improving wound and pressure area care in a nursing home

Wound and pressure ulcer prevention are key quality indicators of nursing care. This article describes a collaborative project between a community skin care service and a nursing home. The aim of the project was to establish whether the implementation of a wound and pressure ulcer management competency framework within a nursing home would improve patient outcomes and reduce the severity and number of wounds and pressure ulcers. Following the project's implementation, there was a reduction in the number of wounds and pressure ulcers, hospital admissions and district nursing visits. Nursing home staff also reported an increase in their knowledge and skills.