J Wound Ostomy Continence Nurs. 2012;39(6):613-621.
Published by Lippincott Williams & Wilkins
CE WOUND CARE
Predictive Power of the Braden Scale
for Pressure Sore Risk in Adult Critical
Care Patients
A Comprehensive Review
Jill Cox
Critical care is designed for managing the sickest patients
within our healthcare system. Multiple factors associated with
an increased likelihood of pressure ulcer development have
been investigated in the critical care population. Nevertheless,
there is a lack of consensus regarding which of these factors
poses the greatest risk for pressure ulceration. While the
Braden Scale for Pressure Sore Risk is the most commonly used
tool for measuring pressure ulcer risk in the United States, re-
search focusing on the cumulative Braden Scale score and sub-
scale scores is lacking in the critical care population. This author
conducted a literature review on pressure ulcer risk assessment
in the critical care population, to include the predictive value of
both the total score and the subscale scores. In this review, the
subscales Sensory Perception, Mobility, Moisture, and Friction/
Shear were found to be associated with an increased likelihood
of pressure ulcer development; in contrast, the Activity and
Nutrition subscales were not found to predict pressure ulcer de-
velopment in this population. In order to more precisely quan-
tify risk in the critically ill population, modification of the
Braden Scale or development of a critical care specific risk as-
sessment tool may be indicated.
■ Introduction
Pressure ulcers (PUs) are encountered in all care settings,
including the intensive care unit (ICU), and are described
as perhaps the most underrated condition within this care
setting.1 Despite implementation of evidence-based pre-
ventive interventions, hospital-acquired PUs continue to
be a major healthcare concern. In 2008, the Health Care
Cost and Utilization Project cited an 80% increase in PU
occurrence between the years 1993 and 2006 in hospital-
ized adult patients, with total associated costs estimated at
$11 billion (US dollars).2 From 2008 to 2009, there was a
slight decrease in the overall prevalence of hospital-
acquired PUs. Nevertheless, prevalence rates in the ICU
remained the highest among hospitalized patients, rang-
ing from 9% to 42%.3-5 In 2009, 3.3% of critical care
Copyright © 2012 by the Wound, Ostomy and Continence Nurses Society™
Copyright © 2012 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
WON200422.indd 613
patients developed deep tissue injuries or stage III, IV, or
unstageable ulcers.5
Pressure ulcer prevention has long been a major focus
of patient care. Recent changes enacted by the US Centers
for Medicare & Medicaid Services restricting reimburse-
ment for hospital-acquired stage III and IV (full-thickness)
PUs have heightened awareness and inspired a renewed
sense of urgency for successful PU-prevention programs in
the acute and critical care settings.6 Despite quality care
and best practices, PUs continue to develop in hospital-
ized patients and the risk is highest among those admitted
to an ICU.7-9
The first step in preventing PUs is accurate identifica-
tion of patients at risk. Traditionally, PU risk measurement
has been accomplished through the use of validated PU
risk assessment tools such as the Braden Scale for Pressure
Sore Risk.10 In the United States, the Braden Scale is the
most widely used risk assessment tool across all care set-
tings, and it is recommended for use in multiple current
clinical practice guidelines.11,12 While limited evidence
suggests that the cumulative Braden Scale score predicts
PU risk in critically ill patients, evidence concerning the
contribution of the instrument's 6 subscales is especially
sparse; only 4 studies were identified that examined the
relationship of subscale scores to PU risk in this
population.13-16
In addition to the factors assessed via the Braden Scale,
a number of other factors prevalent in critically patients
have been found to be associated with PU development.
䡲 Jill Cox, PhD, RN, APN,C, CWOCN, Medical/Surgical Advanced
Practice Nurse/Wound, Ostomy and Continence Nurse, Englewood
Hospital and Medical Center, Englewood, New Jersey and Assistant
Professor of Nursing, Rutgers, The State University of New Jersey.
The author declares no conflict of interest.
Correspondence: Jill Cox, PhD, RN, APN,C, CWOCN, Englewood
Hospital and Medical Center, 350 Engle St, Englewood, NJ 07631
(jill.cox@ehmc.com).
DOI: 10.1097/WON.0b013e31826a4d83
J WOCN ■ November/December 2012 613
31/10/12 1:55 PM
 614 Cox
They include advanced age,1,4,13,14,17-19 lengths of stay in the
ICU of greater than 5 days,1,13,14,18,20 emergent admission to
the ICU,18,21 severity of illness measured via the APACHE II
scale,1,14,22 and various comorbid conditions including dia-
betes mellitus, infection, and cardiovascular/vascular
disease.13,14,17,19,23 Researchers have also evaluated the influ-
ence of iatrogenic factors on PU risk such as the use of va-
sopressor agents.1,14,23 At present, there is insufficient data
to determine the level of risk associated with these factors.
Methods
In order to gain a better understanding of the predictive
power of the Braden Scale for Pressure Sore Risk in the ICU
population, a comprehensive review of the literature was
undertaken focusing on the predictive value of the overall
Braden Scale score and the individual subscale scores in
determining PU risk in the critical care population. The
computerized databases of EBSCO-CINAHL and EBSCO-
MEDLINE were searched using the terms pressure ulcer,
Braden Scale, critical care, intensive care and risk factors.
Journal hand searching and ancestry searching were also
used as search techniques.
Inclusion criteria established for this review included
(1) peer reviewed and published reports on PU risk factors
in adult critical care patients that included the Braden
Scale and/or subscales as variables and (2) studies con-
ducted from 1995 to present. Exclusion criteria were (1)
studies in languages other than English and (2) studies in
which interventions for PU prevention in ICU patients
were the primary focus.
Nine studies were identified that satisfied inclusion/
exclusion criteria.4,13-16,19,24-26 Critical care settings repre-
sented in these studies included medical, surgical, medi-
cal/surgical, and neurologic ICUs. A summary of the
studies included in this review can be found in Table 1.
■ Braden Scale—An Overview
The Braden Scale for Predicting Pressure Sore Risk10 mea-
sures cumulative risk for PU development based on 7 risk
factors measured on 6 subscales (Sensory Perception,
Activity, Mobility, Moisture, Nutrition, and Friction/
Shear) and is based on the conceptual schema developed
by Braden and Bergstrom.27 Subscale scores range from 1
to 4 with the exception of the Friction/Shear subscale,
which ranges from 1 to 3. Each subscale score is clearly
defined by narrative descriptors that assist the clinician
to accurately “match” the patient's status to the correct
subscale level. Pressure ulcer risk is based on a summated
score of 6 to 23, with lower scores indicating greater risk.
Currently, a cutoff score of 18 has been found to demon-
strate the best balance between sensitivity and specific-
ity; thus, clinically this score represents risk for PU
development.28 Some clinicians propose stratification of
PU risk, with scores of 15 to 18 indicating mild risk,
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WON200422.indd 614
J WOCN ■ November/December 2012
scores of 13 to 14 indicating moderate risk, scores of 10
to 12 indicating high risk, and scores of 9 or less indicat-
ing very high risk.29
The Braden Scale has been subject to the most exten-
sive psychometric testing of all the PU risk tools.30 Initial
reliability studies, conducted in skilled nursing facilities,
yielded interrater reliability coefficients ranging from r ⫽
0.83 to r ⫽ 0.99 (P ⬍ .001). In the critical care population,
Bergstrom and colleagues31 reported an interrater reliabil-
ity of r ⫽ 0.89 (P ⬍ .001).
The predictive validity of a PU risk assessment tool can
be assessed using 4 measurements: sensitivity, specificity,
positive predictive value (PPV), and negative predictive
value (NPV) (Figure 1). Sensitivity refers to the tool's abil-
ity to accurately identify patients at risk, and specificity
refers to the tool's ability to correctly identify patients not
at risk, while PPV and NPV describe the scale's ability to
accurately predict patients who will and will not develop
PUs.30 In the critical care population, predictive validity
was first established by Bergstrom and colleagues,31 who
reported 83% sensitivity and 64% specificity, with a NPV
of 85% and a PPV of 61%, based on a cutoff score of 16.
The Braden Scale has been reported to have performed
similarly or better than other risk assessment instruments
in various care settings on measures of predictive
validity.30,32
■ Cumulative Risk
A number of studies have used multivariate analyses to
evaluate the Braden Scale in the critical care setting. Total
Braden Scale score was a significant predictor of PU devel-
opment in critical care patients in 5 of the 9 studies re-
viewed.4,13,15,19,24 In 1 study of 347 medical-surgical ICU
patients,14 statistically significant lower Braden Scale
scores were found between patients who developed a PU
and patients who did not develop a PU (Braden Scale score
13 vs 15, respectively). In another study of 85 medical-
surgical ICU patients,16 the investigators reported a statis-
tically significant difference in Braden Scale scores between
patients who did and did not develop PUs; however, spe-
cific scores were not reported. Wolverton and colleagues26
found lower Braden Scale scores in their sample of 422
critical care patients who developed PUs; however, their
analysis was limited to descriptive statistics. In contrast, a
study of 40 medical ICU patients25 found no significant
difference in Braden Scale scores between patients who
did and did not develop PUs.
Cumulative scores on the Braden Scale in critically ill
patients varied from 9.8 to 15, indicating moderate to
high risk.13,14,15,19,25 The timing of the Braden Scale assess-
ment varied across the studies. In 3 studies, the Braden
Scale score was obtained at the time of admission to the
ICU.14,16,24 The timing of the scores in other studies in-
cluded cross-sectional measurements at the time of data
collection,4,13 mean Braden Scale scores recorded multiple
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WON200422.indd 615
TABLE 1.
Summary of Critical Care Studies Including the Braden Scale/Subscales as Variables Under Investigation (1995 to Present) (Chronologic Order)
Other Risk Factors
Study Sample Size/ Pressure Ulcer Total Braden Sensory Nutrit- Friction/ Significant in Multivariate
Authors Design Type of ICU Incidence, % Scale Score Perception Activity Mobility Moisture ion Shear Analysisa
■ Volume 39/Number 6

Jiricka and Exploratory 85 surgical 56 Xb Xc Xc Xb DUPA scale: Moisture

colleagues16 Descriptive ICU circulation
Carlson and Prospective design 136 medical 12 Xc Xc None
colleagues15 with repeated ICU
measures
Bours and Cross-sectional 850 patients- 28.7 Xc Xc Xc Age, longer length of stay,
colleagues13 design—secondary Dutch ICUs infection
analyses
Fife and Prospective cohort 186 neuro 12.4 Xc Low BMI on admission
colleagues24 ICU
Pender and Descriptive 40 medical 20 No multivariate analysis
Frazier25 correlational design ICU undertaken
Wolverton Descriptive study 422 medical/ 13.7 No multivariate analysis
and surgical and undertaken
colleagues26 neuro ICUs
Shahin and Cross-sectional- 1760 medical, 30 (2002-2005); Xc Age, bowel incontinence
colleagues4 Prevalence 2002-2006 surgical ICU 16.2 (2006)
Slowikowsi Prospective / 369 surgical 23.9 Xc Age ⬎70 y, diabetes mellitus
and Funk19 descriptive ICU
correlational design
Cox14 Descriptive/ 347 Medical/ 18.7 Xb Xb Xc Xb Xc Age, longer lengths of ICU stay,
Correlational design- Surgical ICU cardiovascular disease,
retrospective analysis norepinephrine infusion
Abbreviations: BMI, body mass index; DUPA, Decubitus Ulcer Potential Analyzer; ICU, intensive care unit.
aNot all risk factors investigated are listed, only those factors found significant in multivariate analysis.
bSignificant in bivariate analysis only.
cSignificant in multivariate analysis.
Cox

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615

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 616 Cox J WOCN ■ November/December 2012

FIGURE 1. The elements of predictive validity for a pressure ulcer risk assessment scale.
Based on data from Bolton.30

times,15 and lowest Braden Scale score recorded during the
ICU admission.25 One study did not report when the
Braden Scale score was calculated.19
In the studies reviewed, only 1 group of investigators
provided data regarding interrater reliability. Jiricka and
coworkers16 reported IRR measurements ranging from 88%
to 92%; their study involved 85 medical-surgical ICU
patients. Unfortunately, they provided neither any expla-
nation for the range in IRR nor any description as to how
these data were obtained. No other studies reported mea-
sures of reliability in the published reports.
Measurements of predictive validity, including sensi-
tivity, specificity, and NPVs and PPVs, were reported in 2
of the 9 studies in this review.14,16 Table 2 provides a sum-
mary of studies reporting the predictive validity of the
Braden Scale in adult critical care patients and contains
the 2 studies included in this review,14,16 the initial study
on the predictive validity of the Braden Scale in the ICU
population by Bergstrom and colleagues,31 and 2 addi-
tional studies33,34 that focused exclusively on psychometric
testing of PU risk assessment scales in the critical care
population.
While the majority of patients across all study samples
fell below the established level of 18 and were, therefore,
considered “at risk,” the vast majority of patients re-
mained PU free. In one study of 369 surgical ICU pa-
tients,19 99.5% of the sample fell into the at-risk range
(Braden Scale score ⱕ 18), with 60% of the sample
reporting as high risk or very high risk. However, the in-
cidence of PU development was only 24%. In a second
study of 347 medical/surgical ICU patients,14 94% of the
patients were classified at risk, with 44% of the sample
found to be at high risk or very high risk, but the reported
incidence was 18.7%. Wolverton and associates26 evalu-
ated 422 patients in a medical/surgical ICU; they identi-
fied 92% as being at risk for PU, including 41% at high or
very high risk, but the reported incidence of PU was 14%.
This “overprediction” may represent a flaw in the risk as-
sessment tool or it may reflect the positive effects of
PU-prevention measures; this issue will be addressed in
greater detail.
■ Braden Subscales
Four studies13-16 evaluated Braden subscales (Table 1).
Sensory perception is defined as the ability of the indi-
vidual to perceive and respond to discomfort as a result of
exposure to pressure.10 Examination of evidence reveals
variability in reported influence of this subscale on PU de-
velopment. Two studies15,16 reported that the Sensory
Perception subscale was a significant predictor of PU de-
velopment. In a third study,14 the Sensory Perception sub-
scale was significantly associated with PU development in
a bivariate analysis; however, this subscale did not emerge
as a significant predictor in a multivariate analysis. In con-
trast, a fourth study found no statistically significant

TABLE 2.
Predictive Validity of the Braden Scale in Critical Care Studies
Study Authors Cutoff score Sensitivity, % Specificity, % PPV, % NPV, %
Braden and colleagues 27 16 83 64 61 85
Jiricka and colleagues 16 15 100 10.8 59.3 100
Jiricka and colleagues16 11 75 65 73.5 66.7
Seongsook and colleagues33 16 97 26 37 95
Cho and Noh 34 13 75.9 47.3 18.1 92.8
Cox 14 18 100 7 20 100
Abbreviations: NPV, negative predictive value; PPV, positive predictive value.

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WON200422.indd 616 31/10/12 1:55 PM

 J WOCN ■ Volume 39/Number 6
relationship between the Sensory Perception subscale and
PU development.13
Braden and Bergstrom27 define altered mobility as a di-
minished ability to change and control body position,
which increases the potential for exposure to prolonged
and intense pressure. Two studies found the Mobility sub-
scale score to be predictive of PU development.13,14
Conversely, 2 studies did not find this subscale to be sig-
nificantly associated with PU development in either bi-
variate or multivariate analyses.15,16
Diminished levels of activity (bed-bound or chair-
bound status) influence the duration and intensity of pres-
sure experienced by patients and can contribute to
pressure ulceration.27 None of the 4 studies reporting
Braden subscale scores found the Activity subscale to be
associated with PU development.
Braden and Bergstrom10 state that increased macera-
tion of the skin due to exposure to urine, stool, wound, or
fistula drainage increases its susceptibility to pressure ul-
ceration. Two studies13,16 found the Moisture subscale to be
predictive of PU development, and 2 studies14,15 found no
association between the Moisture subscale and PU
development.
The Nutrition subscale is intended to reflect the indi-
vidual's nutritional intake.27 Nutritional deficiencies lead
to hypoproteinemic states and protein-calorie malnutri-
tion, which can alter the ability of the skin to tolerate pro-
longed exposure to pressure and increase the risk for
pressure ulceration. Cox14 evaluated the contributions of
the Braden Scale and subscales in a study of PU risk factors
in 347 medical-surgical ICU patients. While the Nutrition
subscale was found to be significantly associated with PU
development in a bivariate analysis, this subscale was not
a significant predictor of PU development in a multivari-
ate analysis in this sample of ICU patients. While this is
the only ICU study to find a significant bivariate relation-
ship between the Nutrition subscale and PU development,
no studies examining the Braden subscales found this sub-
scale to be a significant predictor of PU development in
this population.
The Friction/Shear subscale measures 2 conceptually
distinct yet interrelated risk factors. Braden and Bergstrom27
define friction as the force that results when 2 surfaces
move across each other such as occurs from dragging a
patient to change position. Shear is defined as a force cre-
ated by the interplay of gravity and friction, resulting in
damage at the deeper fascial levels.35 While Jiricka and col-
leagues16 found a significant association between the fric-
tion/shear subscale and PU development, Cox14 found this
subscale to be a significant predictor of PU development
in this population.
■ Discussion
Considered collectively, findings from these studies pro-
vide evidence that the cumulative Braden Scale score is a
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WON200422.indd 617
Cox 617
significant predictor of PU risk in the critical care setting.
The Braden Scale is associated with lower specificity and
PPV scores, indicating a tendency to overpredict PU devel-
opment. Analysis of critically ill subjects reveals that virtu-
ally all had a Braden Scale score of 18 or less, but the
majority did not develop a PU. Overprediction of PU inci-
dence is often criticized as a limitation shared by all of the
validated PU risk assessment instruments.30
There are 2 potential explanations of the compara-
tively low positive predictive scores reported in the studies
under review. Administration of the Braden Scale may
have accurately identified patients at risk for PU, resulting
in the aggressive implementation of preventive strategies.
Alternatively, it might be that the Braden Scale failed to
adequately differentiate risk magnitude, resulting in the
implementation of unnecessary and potentially costly
preventive interventions. Based on current evidence, it is
not possible to determine which of these explanations is
most accurate. Thus, caution is recommended when con-
sidering a risk assessment scale's predictive ability, because
the prevention strategies triggered by identification of a
patient “at risk” can substantially reduce the risk of PU
development.36
Another factor that may have influenced the predic-
tive validity of the Braden Scale is the timing of assess-
ments within the individual studies. Some studies based
findings on a Braden Scale score obtained at admission,
while others based findings on a single measurement or
multiple measurements obtained over time. The Braden
Scale score obtained on admission is critical from a clinical
perspective, because it enables prompt identification of
risk and early implementation of prevention strategies.
Basing statistical analysis on a Braden Scale score obtained
at admission provides a consistent point in time of mea-
surement for all subjects in a given study; however, it re-
flects only 1 risk assessment during the ICU admission and
does not capture variability in patient and risk status
throughout the ICU stay. Basing results on a cross-sec-
tional approach reflects risk scores obtained at various
points during patients’ ICU admission and results in a
single measurement obtained at different points during
subjects’ ICU course. Analysis based on a single score mea-
sured on admission or in a cross-sectional analysis does
not take into account the variability in the acuity of illness
experienced by critically ill patients during an ICU admis-
sion, which can impact PU risk. Using multiple measure-
ments over time for a statistical analysis has the potential
advantage of capturing fluctuations and trends in patients’
clinical condition and subsequent changes in PU risk sta-
tus. This approach minimizes the potential for use of a
single aberrant risk score in data analysis that may occur
with other study designs. Due to the variability in ap-
proach to Braden Scale measurement in these studies, the
ability to translate the findings into the clinical arena is
hampered. Perhaps future investigators could use a mul-
tiple measurement approach; such an approach may
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 618 Cox
enhance our ability to determine the true predictive valid-
ity of the Braden Scale. Consistent application of this ap-
proach may also provide clinicians with empirical evi-
dence regarding the optimal point or points in time for PU
risk assessment in the ICU population.
Evidence regarding the contributions of the individual
subscales to PU incidence in the critical care population is
especially sparse and study findings are mixed. In the stud-
ies retrieved in this review, 4 subscales (Sensory Perception,
Mobility, Moisture, and Friction/Shear) demonstrated
varying degrees of predictive value based on a multivariate
analysis, and 2 (activity and nutrition) did not prove pre-
dictive in any study. Determining the relative contribu-
tions of each of the subscales to overall risk is significant
because it helps identify which preventive interventions
are most appropriate for an individual patient. In the cur-
rent era of heightened fiscal accountability, implementa-
tion of risk-appropriate preventive measures is indicated
in order to ensure the best possible clinical and economic
outcomes.
The Braden Scale Sensory Perception subscale was
found to be a significant risk factor in 2 of the 4 studies
that examined the predictive validity of this subscale.15,16
These findings are consistent with current clinical practice
guidelines,12 which emphasize the significance of sensory
impairment and recommend that clinicians implement
preventive measures for patients who score low on the
Sensory subscale, even if the total score does not indicate
significant risk.
The Activity subscale did not emerge as a significant
risk factor in any of the 4 studies that evaluated subscales,
but 2 studies13,14 reported that the Mobility subscale was a
significant predictor of PU development. Though clearly
associated with mobility, activity is defined as the patient's
overall level of physical activity and ranges from bed-
bound to ambulatory.10 Since most critical care patients
are bed-bound, this subscale has limited discriminating
value when applied to a critically ill population. Mobility
takes into account the patient's ability to move indepen-
dently while confined to bed. Therefore, it may provide a
more accurate representation of the critically ill patient's
ability to adjust his or her position to redistribute pressure
and prevent ischemia and ulceration. The Braden sub-
scales of Mobility, Activity, and Sensory Perception repre-
sent related yet conceptually distinct risk factors.10,12 In the
clinical setting, especially in the ICU population, these 3
risk factors (altered mobility, diminished activity, and im-
paired sensory perception) frequently coexist; thus, it can
be difficult to determine the degree to which each indi-
vidual factor contributes to overall PU risk.
The Moisture subscale was found to be a significant
predictor of PU development in 2 studies that enrolled
critical care patients,13,16 although a third study found no
association.14 Two studies conducted in the critical care
setting found that fecal incontinence was an independent
predictor of PU development.1,4 Exposure of the skin to
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WON200422.indd 618
J WOCN ■ November/December 2012
urine and stool is linked to an increased risk for inconti-
nence-associated dermatitis,37 and both may be managed
by indwelling devices in the ICU. Indwelling urinary cath-
eters are common among critically ill patients, especially
since they are also used to provide an accurate measure-
ment of urine output. Indwelling fecal containment de-
vices were introduced in 2004 and have gained popularity
in clinical practice among critically ill patients, although
they are less widely used than urinary catheters.
Preliminary evidence suggests that selective use of these
devices, combined with an evidence-based PU-prevention
program, may decrease PU incidence among ICU patients
exposed to high levels of moisture from liquid stool.38
The Nutrition subscale was not predictive of PU devel-
opment in any study retrieved for this review. The
Nutrition subscale measures the patient's usual food in-
take. Because of the acuity of their illness, most ICU pa-
tients are unable to provide a dietary history, which limits
the predictive value of this subscale in this population.
Sparse evidence suggests that alternative techniques for
measuring the nutritional status of critically ill patients
may prove more predictive. For example, body mass index
and the number of days without nutrition have been re-
ported as significant predictors of PU incidence in the ICU
population.18,24 At this point, we need more data in order
to identify the best physiologic indicator of nutritional sta-
tus in the critically ill patient.39 Commonly used biomark-
ers such as body weight, albumin, prealbumin, and
lymphocyte counts are of limited value due to the intra-
vascular fluid shifts that are common in critical care pa-
tients and that significantly influence both weight and
laboratory values. In addition, evidence linking nutritional
status to PU risk is mixed, and additional research is needed
to more precisely define the nature of this relationship.12,40
The Friction/Shear subscale is included in the Braden
Scale because each of these forces can cause significant
damage to the skin and soft tissue. Friction damages the
epidermal and dermal layers of the skin, while shearing
forces cause angulation and deformation of the blood ves-
sels at the fascia level. Shear forces have been hypothesized
to cause much of the damage associated with full-thickness
pressure ulceration.35 The Friction/Shear subscale emerged
as a significant predictor of PU development in 1 study.14
Many ICU patients require prolonged head-of-bed eleva-
tion for prevention of ventilator-associated pneumonia
and/or to prevent aspiration in patients receiving enteral
feedings; head-of-bed elevation predisposes the patient to
significant shearing forces. Research evaluating the effects
of prolonged head-of-bed elevation on PU incidence is war-
ranted in an effort to better understand the effects of shear
forces on skin and tissue integrity.41
The results of these studies suggest that the clinical
utility of the Braden Scale may be limited. Most critically
ill patients are deemed at risk for PU development when
assessed using the Braden Scale, and it is not yet known
whether the comparatively low predictive values represent
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 J WOCN ■ Volume 39/Number 6
the success of preventive interventions or failure of the
tool to accurately differentiate between patients who are
at risk and those who are not at risk. In addition, there are
factors unique to the critical care population that may in-
crease their risk for PU development, such as the use of
vasopressor agents, prolonged ICU admissions, and co-
morbid conditions; further investigation is needed to de-
termine their contribution to PU risk. If these factors are
found to be predictive of PU development in this popula-
tion, they should be incorporated into a setting-specific,
validated risk assessment tool.1,13,14,17-20,23 Other factors
such as advancing age and low arterial pressure were hy-
pothesized to be related to PU development by Braden and
Bergstrom, even though they ultimately were not included
in the Braden Scale for Pressure Sore Risk.27 A growing
body of evidence suggests that advancing age increases the
likelihood of PU development in the critical care popula-
tion,1,4,13,14,17-19 whereas studies to date have not shown low
arterial pressure to be a risk factor for PU development in
this population.14,19,23,25,42
■ Implications for Research and Practice
The findings of this review reveal multiple opportunities
for additional research including development and testing
of a PU risk assessment tool specific to the critical care
population, either a modified Braden Sale or a newly de-
veloped tool. There is precedence for development of a
modified Braden Scale; the Braden Q Risk Assessment Tool
is a modified and validated version of the Braden Scale
that includes the 6 Braden subscales and an additional
subscale measuring tissue perfusion and oxygenation; it is
designed for use in the pediatric population.43,44
Modification of the current Braden Scale may help to
more accurately identify critical care patients who are at
significant risk for PU development. Redefining the vari-
ous levels within the subscale definitions so that they are
relevant to the critical care population may be one poten-
tial option. The inclusion of other empirically supported
critical care risk factors such as advanced age, prolonged
ICU length of stay, comorbid conditions, or vasopressor
use should undergo further investigation to determine
whether their inclusion might enhance the predictive
power of such an instrument in the critical care setting.
Pressure ulcer risk assessment scales, including the
Braden Scale, tend to overpredict risk; as noted, this may
be due to an inherent weakness in the tool itself or may
reflect the effectiveness of currently used prevention pro-
tocols.30 The majority of ICU patients in this review were
found to be at risk for PU development based on the
Braden Scale score but did not develop a PU; it is unknown
whether this represents true overprediction or is the result
of preventive care. In the first scenario, overprediction
may be the result of an intrinsic weakness of the scale and
results in the unnecessary implementation of prevention
protocols, which could impact healthcare costs. In this
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WON200422.indd 619
Cox 619
case, the refinement or development of a scale that better
measures PU risk in the population would be warranted.
In the second scenario, the apparent overprediction may
reflect the successful implementation of PU-prevention
protocols; identification of the patient as being “at risk”
triggered preventive care that actually prevented PU oc-
currence. Clinically, the second scenario validates the ben-
efits of a comprehensive PU-prevention program. Since
withholding PU-prevention strategies would be unethical,
it is impossible to conduct a study to definitively deter-
mine whether the apparent overprediction is true overpre-
diction or the result of effective care. In clinical practice,
the consequences of underprediction would far outweigh
the costs of overprediction.30
An in-depth analysis of “at-risk” critical care patients
who develop a PU despite prevention strategies compared
to “at-risk” critical care patients who do not develop a PU
may be of benefit. Such an analysis might provide insight
into the risk factors that contribute to PU development in
this population that are not measured by the Braden Scale
and could provide empirical evidence for the development
of a critical care risk assessment scale or a modified Braden
Scale. Such a study might also provide valuable clinical in-
formation regarding the effectiveness of the PU-prevention
program. Development of a PU in a patient who has been
identified as “at risk” and placed on a prevention protocol
may represent some failure or gap in the PU-prevention
protocol or may represent an unavoidable ulcer.
The purpose of all PU risk assessment scales is to pre-
dict PU risk and subsequently mobilize clinicians to imple-
ment prevention strategies that will impede PU occurrence.
Thus, the determination of the predictive validity of a PU
risk assessment scale cannot be made in isolation from the
prevention strategies that are implemented. However, it is
possible that a risk assessment tool designed specifically
for the critical care population could help eliminate true
overprediction and to more accurately identify patients
who need preventive care; thus, further research in this
area is warranted.
■ Conclusion
Research indicates that critically ill patients who develop
PUs are classified as at risk by the Braden Scale, and that
most of the critical care patients who did not develop PUs
were also classified as at risk. At present, we do not know
whether this discrepancy reflects the success of preventive
interventions or inadequate discrimination of risk. While
the subscales Sensory Perception, Mobility, Friction/Shear,
and Moisture have demonstrated predictive ability in crit-
ical care patients, the paucity of empirical investigations
precludes our ability to draw definitive conclusions re-
garding the relative contributions of each of these sub-
scales to PU risk detection and PU development.
Modification of the Braden Scale or development of a crit-
ical care PU risk assessment scale might improve our
31/10/12 1:55 PM
 620 Cox
ability to accurately identify at-risk patients in this popu-
lation and should be addressed in future studies.
KEY POINTS
✔ Limited clinical evidence suggests that the cumulative
Braden Scale score is a predictor of PU development in adult
critical care patients.
✔ Evidence concerning the contribution of Braden Scale
subscales is sparse, and findings are mixed in the critical care
population.
✔ Limited evidence suggests that the Sensory Perception,
Mobility, Moisture, and Friction/Shear subscales are predictors of
PU development in the critical care population.
✔ Modification of the Braden Scale or development of a critical
care specific risk assessment tool might improve our ability to
accurately identify “at-risk” patients in the critical care setting.
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