Critical Review and Analysis of the Braden Scale in Healthcare

This report provides a critical review of the Braden Scale, a widely used assessment tool for predicting the risk of pressure ulcers in healthcare settings. The report begins with an introduction to the importance of assessment in healthcare planning and the specific context of a patient, James, an elderly man admitted for a knee replacement revision, highlighting his risk factors such as diabetes, obesity, and limited mobility. It then describes the Braden Scale, its six assessment categories (sensory perception, moisture, activity, mobility, nutrition, and friction/shear), and the scoring system used to determine the level of risk. A critical analysis of the Braden Scale follows, examining its strengths (comprehensiveness, ease of use) and weaknesses (lack of construct validity, limited focus on skin integrity), drawing on research findings and a SWOT analysis. The report explores the scale's predictive validity and its limitations, especially for specific patient populations like ICU patients and those with diabetes. Finally, the report concludes with a discussion on the effectiveness of the Braden Scale and its applicability in a clinical setting, considering its strengths, weaknesses, opportunities, and threats.

Running head: CRITICAL REVIEW OR ASSESSMENT TOOL
Critical review or assessment tool
Name of the student:
Name of the university:
Author note:

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Table of Contents
Introduction................................................................................................................................2
Description of care situation:.....................................................................................................2
Description of assessment tool...................................................................................................3
Critical analysis of the tool:.......................................................................................................4
Discussion and Conclusion........................................................................................................8
References:...............................................................................................................................10

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Introduction:
Assessment plays a pivotal role in the planning and design of the health care plan or
program and addressing the individualized and specific care needs that any patient population
may exhibit. Assessment in the health care scenario can be defined as the systematic and
scientific procedure which involves a comprehensive and extensive examination of different
aspects of the health status of the patient to arrive at a verdict regarding the exact care need
an in turn a concrete diagnosis. There are an assortment of tools that are available for the
nurses to carry out an extensive assessment, specialized for the particular concern that the
patient might be facing. This assignment attempts to describe, evaluate and critically analyse
an assessment tool, and the chosen assessment tool is the Braden scale (Coleman et al. 2014).
The Braden scale is a specific assessment tool which is associated assessing the risk of
pressure ulcers. Pressure ulcers, also known as pressure injuries, are a very common health
adversity, which presents usually as an exacerbation for critically ill patients or patients who
are mobility restricted and/or are bedridden (Coyer et al. 2015). This assignment will describe
a care situation based on which the assessment tool has been chosen, explore the nature of the
tool followed by a thorough critical analysis of the assessment tool, concluding with an
argumentative verdict on the effectiveness and applicative benefits of the assessment tool in
clinical setting.
Description of care situation:
The care situation selected for this assignment presents the case of a patient named
James, en elderly man in his late fifties, admitted to the Orthopaedics centre for a 2nd revision
total knee replacement surgery. The past history and demographical details of the patient
states that he had been years old when he had to undergo his first half knee replacement after
which he had to undergo 4 more surgeries for the right knee, and as he had been suffering
from infections in the implants, he had been referred to the facility for further treatment. As

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discussed by Getzlaf et al. (2016), unlike any other foreign object knee implants are also
extremely prone to infections after being introduced to the human body and it is also one of
the most important contributing factors leading to multiple surgical requirements after the
implant. Elaborating more on the details shared by the patient, James had shared that he had
to stairs on the regular basis which indicates he had to engage in serious utilization of his
knee on a regular basis which could have led to extra pressure on his knee after his surgery,
which can be detrimental to the health of his knee just after surgery. Along with that, James
had also shared the fact that he is extremely overweight, and is associated with high impact
activities at home and work which also enhanced his risk. Now, overweight individuals also
suffer from higher risk of shearing which can result in high proportion of pressure injuries or
ulcers (Wang et al. 2015).
Another very important aspect of the care scenario is the fact that he had been also
suffering from type 2 diabetes, which is turn is very important risk factor for pressure
injuries. As mentioned by Armstrong, Boulton and Bus (2017), foot ulcers are extremely
common for diabetic patients, with close to 30% and higher chances of diabetic patients
developing foot ulcers. The neuropathic mechanism and decelerated healing seen in the
diabetes is the main contributing factor for the development of the foot ulcerations in the
target patient groups. Hence, along with the excessive shearing due to his heavy weight and
high impact activities throughout the day, the type 2 diabetes is also a notable concern for the
patient enhancing the risk of pressure ulcers. Lastly, his skin integrity scoring had been done
on which he had 22 on the admission and 12 post operation after being bedbound, the heel on
his operated leg looked very sore. Which indicates at the possibility of developing a foot
ulcer, a very common kind of pressure injuries. Hence, Braden scale for pressure injuries had
been a very useful and effective assessment tool which the patient required as per the care
scenario.

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Description of assessment tool:
The assessment tool chosen for the study is the Barden scale, which is an abundantly
used assessment tool for predicting the onset of pressure injuries. It is a scoring system which
is associated with evaluating the risk of the patent for developing a pressure injury by
assessing a few aspects of the skin and physiological functions (Gadd 2014). The Braden
scale is one of the most commonly and preferred tool which assesses different categories for
the assessment of the pressure injuries. Elaborating further, the six categories which is
assessed in the patient for the pressure injury assessment includes sensory perception,
moisture, activity, mobility, nutrition, and friction and shear, all the categories assessed
represent the clinical manifestations that eventually contribute to the development of the
pressure ulcer. Hence, it can be stated based on the above mentioned that this tool is
extensive and takes into consideration all possible routes of clinically manifested sign or
indication to the development of the pressure injuries t ensure that the predicted data is
accurate and the risk of pressure injuries is assessed successfully to avoid the eventual
development of one (Gadd and Morris 2014).
The scoring is numerical based on 3 to 5 range of outcomes, and the final score is also
divided in 5 categories based on a range of scores, judging and calculating the risk of
developing a pressure injury ranging from not at risk (19-23) to respectively preventative
interventions (15-18), moderate risk (13-14), high risk (10-12) to ultimately very high risk (6-
9) (Jin, Piao and Lee 2015). In this case, when the patient was assessed just after admission,
his Braden scale score had been 22, indicating him not being at any risk. Although after the
admission and being bed bound for a few days, his next scoring revealed the score of 12
which indicates high risk of development of a pressure ulcer, validated by the soreness
observed in his heel of the operated leg. Hence, the scale had been successful in assessing the
risk of developing the ulcer effectively.

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Critical analysis of the tool:
The Braden scale had been introduced to the health care field by researchers and
nursing care experts Barbara Braden and Nancy Bergstrom in the year of 1987. The purpose
of the this assessment tool is to aid or assist the health care professionals, specifically the
nurses, to successfully assess the risk of developing an h pressure injury beforehand so that it
can be avoided effectively. As discussed by González-Ruiz et al. (2014), the pressure injuries
are a very common complication which has been attributed to cause a severe discomfort and
trouble for the patient; it is difficult to heal and reduces the quality of living and complicates
the recovery process for the patient as well (García-Fernández, Pancorbo-Hidalgo and Agreda
2014). Hence, the purpose of the development of the assessment tool is relevant to the
clinical practice and valid for improving care quality and enhancing the quality of life and
comfort for the patient population. Researchers are of the opinion that Braden scale is a
potent and easy to used assessment tool which assesses and addresses all of the aspects or
contributing factors leading to the pressure injury development, hence, it can be stated that
Braden scale is a valid tool and it serves the purpose for which it had been developed as well
(Yap et al. 2015).
Considering the literature evidence available on the Braden scale, it can be stated that
the tool has been investigated quite a few times empirical research. Elaborating further, Han
et al. (2018) in the article have specifically explored and evaluated the effectiveness and
utilization advantage of Braden scale in the clinical setting to analyse the exact usefulness of
the tool, specifically for the ICU patients. The study collected and examined electronic health
data in the tertiary hospital by the nurses. The tool and its validity was assessed across each
of the category used for the assessment along with the scoring system and the referral range
for determining the risk as well. The authors in the assessment stated that in terms of
predictive validity and assessment of indicators, the tool is the most suited to be applied in

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the clinical setting, especially for the tests sensitivity, specificity, PPV, and NPV. The authors
in the study also explained that, among the 6 categories of risk factors that constitute the
Braden scale, moisture, mobility, nutrition, and friction and shear were found to be associated
with increased risk of pressure ulcer, while sensory perception and activity were not
associated with increasing risk. Although the scoring and assessment of the subcategories
differed in predicting the risk and actual development of the ulcers. Moreover, patients
assessed as having no risk according to the Braden scale was seen to be developing pressure
ulcers; and, the Braden scale was reported to be limited in the study for predicting pressure
ulcer risk factors. Hence, from the data findings, it can be stated that Braden scale requires
additional elements to be applicable for assessing the pressure ulcer risk in ICU patients. This
view had been supported by many authors, such as Kennedy et al. (2015) has stated that
Braden scale is undoubtedly a break through innovation in order to assess the risk of pressure
injuries ins susceptible patients, although, it can only be used as a preliminary measure, and
cannot be enough as a singular measure to successfully and accurately assess the risk due to
the lack of proper advancement in the subcategories. The article by Sundaram et al. (2017)
provides a contrary or argumentative take to the above mentioned view stating that the
Braden scale can be used as an independent tool for the assessment of the pressure ulcer and
associated length of stay for diabetic patients. The article by Chen et al. (2017) on the other
hand states Braden scale has very limited construct validity for acute care patients and the
data or risk prediction accuracy is limited to sensory perception, followed by mobility and
moisture, hence, there is need for more emphasis on advanced and specialised expansion of
the subcategories.
Assessing the strengths and weaknesses of the Braden scale a SWOT analysis of the
effective use of the tool can be carried out.
Strengths: Weaknesses:

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A comprehensive, easy and simplified tool.
There are six categories that assesses the
risk of development of pressure ulcers based
on the most plausible clinical manifestations
of the underlying process and contributing
factors.
Accurate and easy to interpret scores and
reference range.
Cost effective and mostly accurate results.
Best predictors include sensory perception,
mobility and moisture which also are the
most impactful contributing factors.
Not very advanced and arguable not an
independent and ultimate measure for
accurate prediction of the risk.
Lacks construct validity.
Does not focus more on the skin integrity
and shearing, two very important aspects of
pressure injury development.
Lack of assessment viability on bony
prominences by nurses, which is a common
site for development of pressure ulcers.
Opportunities:
With a specialized and extensive expansion
of the categories on the development of the
tool can lead to better and more accurate
predictions.
Advanced expansion of the tool components
can lead to better construct validity.
Inclusion of more categories for assessment
and respective subcategories can help in
achieving independence of accurate
prediction, even in acute care setting.
Threats:
Lack of construct validity can lead to biased
and inaccurate prediction leading to
harming the patient.
The saturation of the results to only three
basic subcategories for prediction can lead
to confusing prediction.
Hence, based on the above data, there are notable strengths of the assessment tool, although,

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there are also notable weaknesses and threats as well. It has to be commended that this had
been one of the first assessment tools that had been identified in the health care environment
dedicated to the accurate identification of the risk associated with development of pressure
ulcers. Although, the need for more advanced and specialized expansion to enhance its
prediction accuracy across all care setting, especially in acute care and enhancing the
construct validity is extremely crucial.
Discussion and Conclusion:
From the extensive research that has been carried out, it can be stated that Braden
scale is one of the most abundantly used assessment tool in the medical management and
assessment of pressure ulcers. Although, there is an amalgamation of both positive and
negative aspects associated with the tool that has been used for the care scenario and had
been selected. There are other two tools that is also abundantly used for the pressure ulcer
risk assessment including Waterlow scale and Norton scales. As discussed by Araújo, Araújo
and Caetano (2011), the effectiveness and clinical advantage at use for Waterlow scale is far
more effective in predicting the risk of developing pressure ulcers than the Norton scale and
the Braden scale. The authors have further elaborated that both the Norton and Braden scales
are negative scales, indicating that the increase in the detected scores indicate at respectively
reducing chances of developing pressure ulcers, whereas higher the detected score indicates
at higher chance of developing the ulcer in the Waterlow scale. The clarity in the scoring
system itself makes it easier for the staff to depict the exact risk of development of pressure
injuries aptly, especially for newly graduated and transitioning nurses. However, the article
by Moore and Cowman (2014) has instead concluded that there is no statistically significant
difference between the outcomes of using any of these structured risk assessment tools, and
the predictive validity for both Braden scale and Waterlow scale was similar without much
deviation.

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Although, there is also considerable argument contradicting this verdict. The article
by Šateková, Žiaková and Zeleníková (2016) has argued that the predictive validity for
Braden scale is higher than that of Norton scale and the Waterlow scale, with ROC curves
being 0.696 (Braden), 0.672 (Norton) and 0.579 (Waterlow). Hence, it can be concluded that
there is argumentative verdict in the previously published literature on the effectiveness and
clinical advantages associated with the different scales. Yet the majority of the articles that
compare the clinical advantages of using Braden, Waterlow or Norton scale, either deduced
that there is no statistically significant data suggesting the other two scales being superior
than Braden scale, or stated that the Braden scale itself is superior and more effective to sue
in the clinical setting as compared to other two scales.
Hence, although the scale undoubtedly has its own limitations, it can be concluded
based on the 958thorough evidence based literature evaluation, that Braden scale is by far the
most effective structured assessment tool in pressure injury assessment in practice. Although,
the lack of construct validity is needed to be considered in this case as well. There is clear
need for expanding the categories and subcategories of the assessment tool to avoid
saturation of the validity and enhance the accuracy of the tool in the predicting the risk; so
that nurses with even very limited experience can successfully and adequately assess the risk
of pressure injury in the target population as well.

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References:
Araújo, T.M.D., Araújo, M.F.M.D. and Caetano, J.Á., 2011. Comparison of risk assessment
scales for pressure ulcers in critically ill patients. Acta Paulista de Enfermagem, 24(5),
pp.695-700.
Armstrong, D.G., Boulton, A.J. and Bus, S.A., 2017. Diabetic foot ulcers and their
recurrence. New England Journal of Medicine, 376(24), pp.2367-2375.
Chen, H.L., Cao, Y.J., Shen, W.Q. and Zhu, B., 2017. Construct Validity of the Braden Scale
for Pressure Ulcer Assessment in Acute Care: A Structural Equation Modeling
Approach. Ostomy/wound management, 63(2), pp.38-41.
Coleman, S., Nixon, J., Keen, J., Wilson, L., McGinnis, E., Dealey, C., Stubbs, N., Farrin, A.,
Dowding, D., Schols, J.M. and Cuddigan, J., 2014. A new pressure ulcer conceptual
framework. Journal of advanced nursing, 70(10), pp.2222-2234.
Coyer, F., Gardner, A., Doubrovsky, A., Cole, R., Ryan, F.M., Allen, C. and McNamara, G.,
2015. Reducing pressure injuries in critically ill patients by using a patient skin integrity care
bundle (InSPiRE). American Journal of Critical Care, 24(3), pp.199-209.
Fernando, M., Crowther, R.G., Cunningham, M., Lazzarini, P.A., Sangla, K.S., Buttner, P.
and Golledge, J., 2016. The reproducibility of acquiring three dimensional gait and plantar
pressure data using established protocols in participants with and without type 2 diabetes and
foot ulcers. Journal of foot and ankle research, 9(1), p.4.
Gadd, M.M. and Morris, S.M., 2014. Use of the Braden Scale for pressure ulcer risk
assessment in a community hospital setting: The role of total score and individual subscale
scores in triggering preventive interventions. Journal of Wound Ostomy & Continence
Nursing, 41(6), pp.535-538.
Gadd, M.M., 2014. Braden scale cumulative score versus subscale scores: Are we missing
opportunities for pressure ulcer prevention?. Journal of Wound Ostomy & Continence

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Nursing, 41(1), pp.86-89.
García-Fernández, F.P., Pancorbo-Hidalgo, P.L. and Agreda, J.J.S., 2014. Predictive capacity
of risk assessment scales and clinical judgment for pressure ulcers: a meta-analysis. Journal
of Wound Ostomy & Continence Nursing, 41(1), pp.24-34.
Getzlaf, M.A., Lewallen, E.A., Kremers, H.M., Jones, D.L., Bonin, C.A., Dudakovic, A.,
Thaler, R., Cohen, R.C., Lewallen, D.G. and Van Wijnen, A.J., 2016. Multi‐disciplinary
antimicrobial strategies for improving orthopaedic implants to prevent prosthetic joint
infections in hip and knee. Journal of orthopaedic research, 34(2), pp.177-186.
González-Ruiz, J.M., Sebastián-Viana, T., Losa-Iglesias, M.E., Lema-Lorenzo, I., Crespo,
F.J.N., Martín-Merino, G., García-Martín, M.R., Velayos-Rodríguez, E. and Nogueiras-
Quintas, C.G., 2014. Braden Scale and Norton Scale modified by INSALUD in an acute care
hospital: validity and cutoff point. Advances in skin & wound care, 27(11), pp.506-511.
Jin, Y., Piao, J. and Lee, S.M., 2015. Evaluating the validity of the Braden scale using
longitudinal electronic medical records. Research in nursing & health, 38(2), pp.152-161.
Kennerly, S., Boss, L., Yap, T.L., Batchelor-Murphy, M., Horn, S.D., Barrett, R. and
Bergstrom, N., 2015, September. Utility of Braden scale nutrition subscale ratings as an
indicator of dietary intake and weight outcomes among nursing home residents at risk for
pressure ulcers. In Healthcare (Vol. 3, No. 4, pp. 879-897). Multidisciplinary Digital
Publishing Institute.
Moore, Z.E. and Cowman, S., 2014. Risk assessment tools for the prevention of pressure
ulcers. Cochrane Database of Systematic Reviews, (2).
Moore, Z.E. and Cowman, S., 2014. Risk assessment tools for the prevention of pressure
ulcers. Cochrane Database of Systematic Reviews, (2).
Šateková, L., Žiaková, K. and Zeleníková, R., 2017. Predictive validity of the Braden Scale,
Norton Scale, and Waterlow Scale in the Czech Republic. International journal of nursing

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practice, 23(1), p.e12499.
Seong-Hi, P.A.R.K. and Lee, H.S., 2016. Assessing predictive validity of pressure ulcer risk
scales-a systematic review and meta-analysis. Iranian journal of public health, 45(2), p.122.
Sundaram, V., Lim, J., Tholey, D.M., Iriana, S., Kim, I., Manne, V., Nissen, N.N., Klein,
A.S., Tran, T.T., Ayoub, W.S. and Schlansky, B., 2017. The Braden scale, a standard tool for
assessing pressure ulcer risk, predicts early outcomes after liver transplantation. Liver
Transplantation, 23(9), pp.1153-1160.
Wang, L.H., Chen, H.L., Yan, H.Y., Gao, J.H., Wang, F., Ming, Y., Lu, L. and Ding, J.J.,
2015. Inter‐rater reliability of three most commonly used pressure ulcer risk assessment
scales in clinical practice. International wound journal, 12(5), pp.590-594.
Yap, T.L., Rapp, M.P., Kennerly, S., Cron, S.G. and Bergstrom, N., 2015. Comparison study
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Appendix:
U40420/P40402
Adult Pro forma for assessment : These observations are post op.
Biographical details
Patient James (Pseudonym due to NMC code of privacy and confidentiality) is admitted to
Orthopaedics centre. James is in his late fifties. He was admitted for 2nd revision total knee
replacement. He is living in Milton Keynes and professionally works as chef.
James’ live in house with family. James’ educated to graduation level. He has 4 children
and wife.
The reason for contact with health care services
According to James he was 40 years old when his first half knee replacement took place.
He told me that since his first surgery things have changed and he had 4 surgeries for his
right knee. Therefore, this time due to infection around his Knee implants, he was referred
to orthopaedics for the treatment.
Your perspective/understanding
James is very polite person who lives in house where he uses stairs on regular basis. Due to
this his knee has not been able to recover or stayed intact for longer.
James has excessive heavy weight. His high impact activities at home and work made the
situation worse for his knee recovery. After this operation James plans to avoid using stairs
as much as possible.
Relevant Medical/Psychiatric History
James is also suffering from diabetes type 2. He had 4 surgeries performed for his right
knee. This time he was admitted for 5th operation.
James’ height is 5’3” tall and BMI is 44.
Family History
No history of knee replacement in family. James’ father had hip replacement when he was
80 years old.
Social history
James has good social life. Since his admission he has family and friends’ visits.
He spends his time going to pubs and watch football with his friends over the weekend.
Developmental stage/history

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First half knee replacement when he was 40 years old. 2nd surgery was for first washout and
3rd was done for total knee readjustment. His 4th was done for a total knee replacement at
the age of 50. This time James was admitted to have washout due to infection in his knee.
Review of Systems
System Comments Assessment tool/s
Skin A score of 22 on admission.
A score of 12 post operating
observation. Risk of
developing an ulcer increased
as patient was bed bound and
heal skin on the operated leg
looked sore.
Braden scale.
Head,ears, eyes, nose, mouth,
throat, neck
All intact.
Respiratory Breathing is fine, Respiration
rate was 18 breaths /minutes.
NEWS (National early
warning score) chart.
Breast and lymphatics Fine.
Cardiovascular Blood pressure is regular and
stays at 130/81 post op.
Pulse is also regular between
70 and 78.
MEWS chart.
Gastrointestinal
Fine.
Bristol stool chart.
Urinary
No UTIs’.
urinalysis
Musculoskeletal
Patient is not able to bare
weight on right leg and could
hardly move it due to scar.
Nursing Diagnosis