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Effective Way to Utilize


The purpose of this curriculum is to teach new nurses on effective use of the Braden scale score and ways to develop an accurate plan of care.  The development of pressure ulcers is still a problem in health care facilities, even with the use of different risk assessment scales. Braden scale is one of the most commonly used tools to predict pressure ulcer development in patients. Many studies have indicated that the lack of knowledge on proper utilization of the risk assessment tools by healthcare providers is one of the major barriers to successful prevention of pressure ulcers. Studies have found that using the cumulative Braden score alone does not prevent pressure ulcer rather paying attention to the subscale score has proven to be effective in the prevention of  pressure ulcer. Research studies have shown that interventions carried out based on subscale score had better outcomes; the workload for the nurses was decreased because the unnecessary interventions were eliminated. This teaching program will teach the nurses how to effectively score the patients using Braden Scale and generate proper interventions based on the total score and subscale scores. The Outcomes of this program will include a significant decrease in the number of pressure ulcers.

Pressure Ulcers: A Serious Health Care Problem

Development of pressure ulcers is a critical health care problem and its prevention have been a major problem in health care facilities. The development of pressure ulcers is common and it causes pain and affects the life of people on a wide scale. It also plays an important role in increments of costing for their health care and is linked to deaths in large numbers. The pressure ulcers develop fast and heal very slowly, which can be months or even years. Sometimes, pressure ulcers require surgeries for completely heal (Mertens, Halfens, Dietz, Scheufele, & Dassen, 2008). The treatment and prevention of pressure ulcers are very costly and it is associated with the deaths of a large amount of people every years in the United States (Li & Korniewicz, 2013).

Preventative programs for at-risk patients have been shown to be effective in reducing the agency’s prevalence rates (Kring, 2007).  Therefore, identifying patients who are at risk is a vital first step in pressure ulcer prevention. These programs have also shown that health care providers cannot always accurately predict who will develop pressure ulcers based on a global assessment; routine use of risk assessment tool is recommended. The Braden scale is one such tool and it is the most commonly used tool in the United States for evaluating the magnitude of risk for pressure ulcer development (Kring, 2007).

The goal for writing this paper is to educate healthcare professional on how to effectively use the 'Braden Scale.' Pressure ulcers are preventable under certain conditions. A lot of researches have proved that the problem between the predictions of potential patients carrying out the proper intervention based on the score is the lack of necessary knowledge of healthcare professionals regarding the risk assessment tool. Assessment of the risk is not only one time activity to perform, but the patients should be assessed periodically. Specifically, whenever there is a change in health status (Berlowitz 2013). History of the patients and physical examination can show correct predisposing factors in the patients and specific steps should be taken for measurement of the risk level. As it is a continuous task which requires regular follow ups and daily skin inspection should be performed for detection of early symptoms. This course will be of help to the healthcare professional and will teach adequate strategies to come up with interventions that are necessary for the prevention of pressure ulcers via subscale scores.

A  Pressure ulcer is a health care quality indicator and it is very important to eliminate avoidable pressure ulcers  (Defloor & Grypdonck, 2005). The Braden Scale is highly used and easy to use a scale that is common for measurement. However, the survey shows that acute care nurses did not correctly identified the purpose of Braden Scale and the survey was conducted with 629 U.S and Canadian acute nurses (Magnan & Maklebust, 2009). A study was conducted especially to evaluate the effect of the training via web sites on Braden subscale ratings for convenient sample of RN working at three Michigan medical centers. The RN participants included nurse who was involved in the use of Braden Scale regularly (regular users) and the nurses who did not use the scale (new users). Data was collected to determine the amount of nurses making reliable Braden subscale assessments. Nurses were then asked to complete a web-based training module and again the data were collected to monitor. The reliability of nurses’ Braden subscale ratings was determined by examining the level of agreement/disagreement between ratings made by an RN and an “expert” rating the same patient. After going through the web based training module the reliability of nurses increased, but it increased only for the new users and had no significant effect on the regular users. This study was conducted by Magnan and Maklebust in the year 2009.

More studies were performed out of which the one performed by Dallaire, Gallant, Morin and St-Germain in 2010 performed a descriptive correlational study of the examination of nurses’ knowledge and the best practices based on Braen scale scores. The study showed that the knowledge of nurses regarding the pressure ulcers and it`s treatment is highly insufficient. Another study which was performed by Tescher, Branda, Bryne & Naessens (2012) showed that the total Braden Scale score is predictive of pressure ulcer development, but it does not help to develop an individualized targeted prevention plan. However, the use of subscale scores can enhance the prevention programs. From the subscales, the friction and shear subscale had the greatest predictive power among Braden Scale scores. Unfortunately, Dallaire, et al. (2010) showed nurses lacking knowledge in that particular subscale.

It has been stated that the effective use depends on the accuracy in identification of those at risk. It not only mobilizes preventive strategies, but at the same time also decrease inappropriate use of resources which result in a decrease, in the overall cost of care. The cost of prevention is substantially lower than the cost of treatment (Bergstrom, Braden, Kemp, Champagne, & Ruby, 1998). The data provided in above research support the Braden Scale as an effective tool in identifying patients at risk for developing pressure ulcers. The proper utilization of preventive measures by health care professionals based on the Braden score has the potential to significantly decrease the incidence of pressure ulcers in older adults. Unfortunately, all of the above studies found that the nurses had little knowledge in identifying the risk factors and needed a great deal of education in applying appropriate interventions based on the Braden subscale scores.

Braden Scale Tool

The Braden Scale which is a summated rating scale and contains six subscales was developed to help nurses in predicting risk for the development of pressure ulcers and taking subsequent preventative measures (Bergstrom, et al., 1998). The appendix A1 shows that how to score each subscale based on nursing assessment and the sum of all the subscale scores is the total score. The total score range is from 6 till 23. It is composed of six factor subscales sensory perception, moisture, activity, mobility, nutrition and friction/shear. Each factor scale is rated one to four, except for friction/shear, which is rated one to three. The sum of all the scales is used to measure the overall risk of pressure ulcer development where scores 19 to 23 indicates no risk of development, 15 to 18 indicates mild risks, 13 to 15 shows moderate risks, 10 to 12 indicates high risk and from 6 to 9 demonstrates very high risk (Tescher, et al., 2012).  The study done by Berstrom, et al (1998) to identify the critical cutoff point that demands the need for intervention. It showed that the patients having scores of less than 18 are at very high risk and nurses should come up with an appropriate intervention to prevent the development of pressure ulcer. This procedure will not only look at the total score, but will also take in consideration the six subscale factors which could indicate risk where the total score can be low or no risk.

The Braden Scale consists of six subscales that measure the two primary etiologic factors in ulcer formation: intensity and duration of pressure exposure and tissue tolerance. The first three subscales, sensory perception, activity, and mobility, assess clinical situations, predisposing the patient to intense and prolonged pressure. The remaining subscales, nutrition, moisture, and friction/shear, assess factors adversely affecting the tissue tolerance for pressure. Healthy individuals are continuously moving and readjusting their body posture to prevent excess pressure and shear forces. Reduced mobility or sensation interrupts this natural response, rendering an individual vulnerable to tissue damage (Elliott, 2010).  Frequent turning and reassessment of a patient with friction and shear score of less than two can help prevent pressure ulcer development.

The study conducted by Lindgren, Unosson, Fredrikson & Ek (2004) confirmed that immobility is a risk factor of major importance for pressure ulcer development among adult hospitalized patients. Repositioning should be undertaken on an individual basis in line with ongoing skin evaluation, avoiding bony prominences. The skin should be closely monitored to ensure effectiveness of the regimen and further actions taken if any signs of tissue damage occur (Elliott, 2010). Nutrition and tissue loading are two areas of nursing influence. Strategies to ensure optimal nutrition should be used; the provision of oral nutritional supplements have been associated with reduced tissue breakdown (Elliott, 2010). A Study conducted by Omote, Sugama, Sanada, Konya, Okuwa & Kitagawa (2005) found improvement in wound healing following a change in nutrition for a length of four weeks. Increase in overall intake of Kcal in general made a difference.

According to Dallaire et al., (2010) moisture is one of the Braden subscales on which nurses score low in applying preventative measures. Magnan & Makelbust (2009) related that moisture risk level is determined by number of linen changes. Moisture requiring three or more linen changes in a shift translates to a risk level of one, which means constantly moist.


This curriculum used an instructional design (indirect instructional strategy) to educate the learners. Indirect instructional design is a learner-centered strategy in which demands a high level of student involvement. This strategy requires reading the materials provided and applying this information learned from this case study by coming up with an appropriate plan of care using “the steps of nursing process.” Using critical thinking, the students are required to assess, diagnose and plan their care more effectively. This method allows students to learn and gain a deeper level of understanding of the materials.  By using the “nursing process steps” which the nurses were already familiar. This process can enhance the learning and at the same time can result in more engaged learning. The students will be able to construct the knowledge through synthesizing information provided and integrate the new skills into what they already know.

Application of nursing process in developing plans of care for at-risk patient is used as a conceptual framework for this curriculum. The goal of the curriculum is that the learners will be able to master the following learning objectives at the end of the course.           


The course will make students:

  1. Recognize the at-risk patient based on the total Braden Scale Scores
  2. Identify the six subscales of the Braden Scale
  3. Students will be able to link sub scores of Braden Scale to the total score and develop an appropriate plan of care using steps of the nursing process.                                             

The assessment part of the nursing process includes assessing and identifying the at-risk patients using the Braden Scale tool (Appendix A1). According to Magnan & Maklebust (2009) when working with Braden Scale, the total score provides the information needed to make the “at risk” diagnosis. Whenever the Braden Scale total score is 18 or lower, it can be concluded that the patient is at risk for pressure ulcers. Once the patient is identified as at risk for developing pressure ulcers, the nurse should construct a nursing diagnosis that identifies what the patient is at risk for and the factors that place the patient at risk. Therefore, it is important to determine which specific factors place the patient at risk for developing a pressure ulcer. Paying attention to the subscale scores can help nurses identify the specific factors.

A subscale rating of three or lower on the sensory-perception, moisture, activity, mobility, or nutritional subscale means that that factor is a source of risk. A rating of two or lower on the friction-shear subscale means that friction-shear is a source of risk (Tescher, et al., 2012). The diagnosis should identify the specific risk factors that place the patient at risk for pressure ulcers and the next step is to plan the preventive interventions. When planning preventive interventions, nurses should develop a goal that focuses on the risk reduction of specific subscale factors identified and develop a plan of care based on the goal. Students will be able to refer to sample plan of care on appendix A2 as a guide when developing plans of care based on subscale risk factors. For example, if the patient scores less than two on friction/shear subscale, the goal should be focused on preventing the development of pressure ulcer by planning, preventative interventions that are specific on reduction of friction/shear on the skin such as keeping the bed linens clean, dry and wrinkle free, avoid massaging pressure points.

Students will apply transparent dressing or elbow/heel protectors to intact skin over elbows and heels. Implementation is the next step once the interventions are planned; implement them immediately to achieve the goal of pressure ulcer prevention. Magnan, et al. (2009) described nursing implementation as either direct or indirect. Direct care interventions involve a direct interaction between the nurse and the patient, such as applying transparent dressing to elbows/heels to protect the intact skin. Indirect interventions occur when the nurse delegates care to another (delegating turning patient to a nursing assistant) or consults others (consulting a dietician) to achieve patient-centered goals. The final step in nursing process is to evaluate whether the goals are being met. If the outcome is positive, and the patient remains free from pressure ulcers; it indicates that the preventative interventions were successful. If the outcome is not positive, and the patient develops a pressure ulcer, the student need to re-assess the patient for risk, develop new diagnosis, according to the risk, planning preventative interventions based on the risk, implementation of the interventions and re-evaluate the outcome (as shown in appendix A 3). Students will be able to develop an accurate plan of care using this strategy.

Pilot Study

A pilot study was conducted with a small group of nursing students (six nursing students) to obtain initial information on the effectiveness of the program. The study took place at the St. Francis Hospital on April 3, 2014 during their clinical rotation. Each student’s knowledge and the ability to use the Braden Scale Score was evaluated by giving them a case study, a type questionnaire (Appendix A4), to test their extent of knowledge on the topic. The result of that test is scored and recorded as a pre-learning knowledge. Students were then provided with the “Braden’s pressure ulcer risk assessment tool” developed by Barbara Braden & Nancy Bergstrom in 1988 (as shown in appendix A 1). This tool was used by the students as a guide in identifying patients that are at-risk for developing pressure ulcers and planned the care accordingly using “steps of nursing process” (which the students are already familiar with; Appendix A2). Table in appendix A1 explained the Braden Scale in detail, which rates patients in six subscales: Sensory perception, Moisture, Activity, Mobility, Nutrition and Friction/Shear using scores ranging from 1 to 4 scale (1 to 3 for Friction/Shear scale only). The maximal total score is 23; a score of 18 or less indicates high risk, in which case requires appropriate nursing intervention to prevent pressure ulcer. The students would utilize the sample plan of care table in appendix A 2 as a guide to help them develop an accurate plan of care using the nursing process technique explained in appendix A 3. Students were first observed based on their prior knowledge and were scored (Data 1). Subsequently, students were instructed to assess and plan their care based on individual subscale criteria. The results were also recorded (Data 2).           

The recorded data were used to assess the accomplishment of the “learning of the objectives” by comparing the pre-teaching and post-teaching case study results. Prior to teaching, the students were able to successfully come up with the total score for the patients in the case study; however, they were unable to develop an effective plan of care to the respective assessment scores. The plan of care that the students developed were focused solely on the total score, and failed to address individual risk factors relative to the sub-scores. As a result (see data 1.), the patients were being treated in a standardized manner, leading to the loss of individual approach, as each patient care is essentially different. This standardized approach could eventually lead to unnecessary tests and procedure that could have easily have been prevented if the patient were treated correctly the first time. Thusly, the students were taught about the values and the essentials of the Appendix A2 (developing the plan of care using nursing process); which allowed them to focus on the area where they performed poorly and to work on that specific sub-scale score during this period. Students showed significant improvement after the teaching. In the post-teaching case study, students not only score the at-risk patients correctly, but they also picked up on the sub-score, risk factors and developed a proper plan of care based on the specific needs of the patient. By comparing the results of pre-teaching and post-teaching, it indicated that this teaching method was able to produce the behavioral change required to meet the objectives of this curriculum.

Summative evaluation is used to assess effectiveness of this teaching method. Each student evaluated the teaching method by completing the evaluation form (Appendix A5) which allows them to rate the teaching method on a scale of one to four; the higher the score correlates to its effectiveness. This gave the program opportunity to immediately identify and address problems with instructional materials. Every student unanimously agreed that this project improved their knowledge and effective application of the Braden Scale Score. The average rating for objectives, clarity and understandability of the materials were 4/4.  The effectiveness of the teaching method was rated 3/4, making this a successful teaching program.

A Pressure ulcer is a preventable condition and it is the responsibility of the healthcare professionals to prevent pressure ulcer from developing on their patients. All of the studies discussed above agreed that early intervention is necessary for preventing and minimizing risk of pressure ulcer development once risk is identified. The Braden Scale is a very reliable and accurate predictor of the at-risk patient (Kring, 2007). Health care professionals can use this tool to prevent pressure ulcer by performing an early risk assessment and intervention. This teaching method can be used as a guide in identifying at-risk patients and planning care for prevention of pressure ulcer using the Braden score and subscale scores. Ultimately, accurate identification of the risk factors for pressure ulcers and implementing evidence-based prevention strategies can lead to reductions in both the occurrence of pressure ulcers and health care costs and can promote positive health outcomes for the patients (Cox, 2011).



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Bergstrom, N., Braden, B., Kemp, M., Champagne, M., & Ruby, E. (1998). Predicting pressure ulcer risk: A multisite study of the predictive validity of the Braden Scale. Journal of Nursing Research, 47(5), 261-269.

Blumberg (2004). Beginning journey toward a culture of learning centered teaching. Journal of Student Centered Learning, 2(1), 68-80.

Cox, J. (2011). Predictors of pressure ulcers in adult critical care patients. American Journal of Critical Care, 20(5), 364-374.

Dallaire, D., St.Germain, D., Morin, D, & Gallant, C. (2010). Prevention and treatment of pressure ulcers in a university hospital centre: A correlational study examining nurses’ knowledge and best practice. International Journal of Nursing Practice, 16, 183-187.

Defloor, T., & Grypdonck, M. (2005). Pressure ulcers: Validation of two risk assessment scales. Journal of Clinical Nursing, 14, 373-382.

Elliott, J. (2010). Strategies to improve the prevention of pressure ulcers. Nursing Older People, 22(9), 31-36.

Kring, D. L. (2007). Reliability and validity of the Braden Scale for predicting pressure ulcer risk. Journal of Wound, Ostomy and Continence Nurses, 34(4), 399-406.

Li, D., & Korniewicz, D. (2013). Determination of the effectiveness of electronic health records to document pressure ulcers. Medsurg Nursing, 22(1), 17-25.

Lindgren, M., Unosson, M., Fredrikson, M., & Ek, A. (2004). Immobility-a major risk factor for development of pressure ulcers among adult hospitalized patients: a perspective study. Scandinavian Journal of Caring Sciences, 18, 57-64.

Magnan, M., & Maklebust, J. (2009). The effect of web-based Braden scale training on the reliability of Braden subscale ratings. Journal of Wound, Ostomy & Continence Nurses Society, 36(1), 51-59.

Mertens, E. I., Halfens, R. J., Dietz, E., Scheufele, R., & Dassen, T. (2008). Pressure ulcer risk screening in hospitals and nursing homes with a general nursing assessment tool: evaluation of the care dependency scale. Journal of Evaluation in Clinical Practice, 14, 1018-1025.

National Guideline Clearinghouse (NGC). Guideline summary: pressure ulcer prevention and treatment protocol. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); [cited 2013 March 21]. Available:

Omote, S., Sugama, J., Sanada, H., Konya, C., Okuwa, M., & Kitagawa, A. (2005). Healing process of pressure ulcers after a change in the nutrition regimen of bedridden elderly: A case series. Japan Journal of Nursing Science, 2, 85-93.

Tescher, A., Branda, M., Byrne, T., & Naessens, J. (2012). All at risk patients are not created equal: Analysis of Braden pressure ulcer risk scores to identify specific risks. Journal of Wound, Ostomy & Continence Nurses Society, 39(3), 282-291.

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