Pressure Ulcer Prevention: Evaluating Risk Assessment Scales

This report provides a comprehensive analysis of pressure ulcer prevention, focusing on the comparison between the Braden and Waterlow scales for risk assessment in healthcare settings. The introduction highlights the prevalence and impact of pressure ulcers, particularly among the geriatric population, emphasizing the need for effective prevention strategies. The report outlines a systematic search strategy, detailing the databases used (CINAHL, Google Scholar, Cochrane, and Medline), keywords, and selection criteria for relevant literature. It then critically appraises key studies, including Cowan et al. (2012) and Gadd (2012), evaluating the effectiveness of the Braden scale in predicting pressure ulcer risk. The report discusses the implementation of evidence into nursing practice, identifies barriers to implementation, and suggests strategies for improving pressure ulcer prevention in clinical settings, specifically in Saudi Arabia. The conclusion summarizes the key findings and emphasizes the importance of ongoing research and the use of evidence-based practices to reduce the incidence and burden of pressure ulcers.

Running head: PRESSURE ULCER PREVENTION
Pressure ulcer prevention
Name of the Student
Name of the University
Author note

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Table of Contents
Introduction......................................................................................................................................2
Clinical question..............................................................................................................................4
Systematic search strategy...............................................................................................................4
Critical appraisal and summary of study findings:..........................................................................7
Implementation of evidence into nursing practice.........................................................................11
Conclusion.....................................................................................................................................15
References......................................................................................................................................17
Appendix........................................................................................................................................23

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Introduction
Pressure ulcers (PU) or bedsores are caused due to prolonged pressure on the skin and its
underlying tissue. It is prevalent among people especially geriatric population as they are
confined to the bed or wheelchair for long periods (Black et al., 2011). There are developments
of discoloured patches that are warm, hard or spongy creating itchiness or pain in the affected
area. PU differs in size and affects tissue layers from skin erythema to bone damage. The
problem of PU is common being a medical complication among the older population. In
Australia, prevalence of PU is between 3.4 to 5.4% in aged care homes as reported by Australian
Wound Management Association (AWMA) (Care, 2011). This problem induces suffering and
deterioration in quality of life with prolonged hospitalization among the patients and therefore,
pressure ulcer prevention are important parameters (Lyder et al., 2012). Therefore, PUs among
the aged care people is a clinical issue that have a significant effect on the quality of life with
increasing care costs and long hospital stays.
Pressure ulcers and related injuries not only impose significant burden on the patient, but
the entire healthcare system. It has severe negative impact on the patient and healthcare system
like increased infection rates, pain, morbidity, mortality, increased hospital stays and financial
costs (Coleman et al., 2014). The frequency and prevalence of PUs need to be reduced which is
an essential component for patient safety and quality of care. It is evident that potential risk
factors for PU need to be assessed early that may influence clinical practice for the PU
prevention and improvement in quality of care. The prediction of risk of PUs is a nursing issue
and requires immediate risk assessment. The prevention of PU development is the best way to
reduce the burden of PU for the healthcare system being their core aim (Sullivan & Schoelles,
2013). The implementation of PU prevention guidelines can help to prevent PUs that target the

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risk factors related to PU development (Moore and Cowman, 2014). Concisely, the
understanding and identification of risk factors in the PU development can aid in developing
prevention interventions and better utilization of resources in clinical practice.
According to Coleman et al., (2013) three main factors contribute to PU development:
perfusion alterations, mobility/activity and skin status. For the assessment of these risk factors,
PU risk assessment tools are important component for the identification of patients at risk of
developing PU. The checklist comprises of Braden Scale, Waterlow Scale and Norton Scale that
are currently in use. These tools are valid, reliable, specific and sensitive by identifying the
individuals at risk in a consistent manner. However, there is little information available regarding
the reliability and validity of these tools and that acts as big challenge for the clinical setting.
Evidence also suggests that specificity and sensitivity of risk assessment tools vary in different
healthcare settings because of clinical judgment made on obtained risk assessment results
(García-Fernández et al., 2014).
According to Šáteková & Žiaková, (2014) among the most frequently used PU risk
assessment scales, Braden scale demonstrated optimal predictive validity. However, there is a
need to examine other scales in respective clinical settings and comparison with foreign studies.
On the other hand, another study conducted by Ang, Chang & Tay, (2014) showed that Braden
scale showed moderate predictive validity with low predictive specificity for PU risk assessment.
Therefore, further development and testing of risk assessment scales is important for
identification of PU risk factors and prevention.
From the above discussion, it is clear that risk assessment is important at the time of
admission and at periodic time intervals. According to Centres for Disease Control and

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Prevention (CDC), the healthcare professionals use these risk assessment tools being the best and
effective approach for PU prevention (Centres for Disease Control and Prevention, 2012).
Various tools are used for the risk assessment like Braden, Norton and Waterlow scale PU
assessment help healthcare professionals to identify individuals who might develop PU.
Therefore, the aim of this paper is to evaluate the effectiveness of Braden scale and Waterlow
scale for the assessment of PUs through systematic search strategy, identification of barriers and
strategies to implement the evidence in the clinical setting of Saudi Arabia.
Clinical question
In patients at risk for pressure ulcers, does Braden scale as compared to Waterlow
scale prevent the incidence of pressure ulcers?
Systematic search strategy
Methodology: For the alignment of the research question with the aim of the research that is
proposed, a systematic literature review is beneficial. The current trends of PU prevention in
different clinical settings are to be analysed based upon strong evidence and gather the best
evidence from the systematic literature review. This method is aimed at identification, evaluation
and summarization of the major findings so that best available information can be retrieved and
help to draw the evidences into practice (Liamputtong & Serry, 2013). Relevant literature can be
extracted from the vast pool of evidences and helpful in drawing conclusion for the
implementation into practice. The summarization of the key findings and identification of the
literature gaps along with future scope for research are the main aims of systematic literature
strategy. For the present study, a systemic literature strategy was carried out for understanding
the effectiveness of Braden scale as compared to Waterlow scale in the prevention of PUs among

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the patients at risk. The scientific design was important during the literature search and
accordingly, appropriate sources were retrieved from the credible sources in a logical and
systematic manner through appropriate search strategy (Maxwell, 2012).
Databases used: Appropriate search engines were used for carrying out the literature search
reviews. Identification of databases is important as it provides ample of information on any
subject matter. The electronic databases used for the present study were CINAHL, Google
Scholar, Cochrane and Medline. These databases help to provide wide range of information
regarding every subject and also have proper access to the full text articles that are authentic.
These databases are reliable and provide up-to-date information covering many journals. The
update information is important for the study and so, these databases provide up-to-date
information.
Keywords/search terms- Keywords or search phrases are important for carrying out a
systematic literature search. The commonly used words that are important phrases in the clinical
research question are used in the search engines for the search. When the keywords are entered
appropriately with maximum number, systematic literature review is considered successful. For
the present study, the search items used are “pressure ulcer”, “pressure ulcer prevention”, “risk
assessment”, “Braden scale”, “Waterlow scale”, “incidence of pressure ulcer”.
Boolean operators- Apart from the appropriate key search items, Boolean operators are also
important in the search strategy. These logical items are used in conjunction with the key search
words for the authentic and reliable search. The Boolean operators used make the search smooth
and inclined towards correct direction. Only the relevant data was extracted from the search and

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the inappropriate items were eliminated from the search. OR and AND were used for the present
study and applied for each database search method.
Selection process- This is the most important part of a systematic search strategy as it requires
arduous research to include the articles that are relevant to the study and contains updated
information (Smith et al., 2011). A selection criterion is selected for the present study through an
inclusion and exclusion criteria adhering to the current selection criteria (Uman, 2011). For the
present study, thorough examination was done which is defined as the inclusion criteria. The
articles published after the year 2010 was included for the study. Full-text articles were only
included for the study searching in every databases and around fifteen relevant articles were
selected for the study. This was the first round of selection based on the article paper name and
in the second round of screening, the abstract of the articles were read for relevancy. Finally, six
relevant contemporary articles were included in the present research study. All the articles that
were published in English were included from different countries. These articles have studied the
effectiveness of the risk assessment tools; Braden scale and Waterlow scale for the risk
assessment in patients at PU risk.
Data extraction- For extracting the relevant information, a critical analysis of the articles was
done. The critical appraisal was done for the study that included a checklist like aim, research
methods, findings, conclusion, discussion and limitations. It also included information like
research gap limitation and scope for future studies.
Data analysis- For the data analysis, the articles were reviewed properly before the presentation
of the findings. This kind of literature review gives an opportunity to assess the quality of study,
efforts made in the research and in identifying the gaps, limitations and scope for future studies.

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Apart from the research findings, the arguments and contradictions that were presented in the
paper were also highlighted. When these points are considered, it helps to give a deep insight on
the research topic and provide scope for comparison between the literatures.
Critical appraisal and summary of study findings:
The paper by Cowan et al., (2012) was aimed at studying the PU predictive model that
was identified in the acute care settings for the assessment of PU risk by Braden scale. The paper
beautifully addressed the effective use of Braden scale in the risk assessment in acute care
settings and addressed the clinical significance of the study. The literature review of the paper is
comprehensive explaining the significant challenge faced by the healthcare system in PU
prevention. The review has incorporated the essential elements like the specificity and sensitivity
of Braden scale that is poorly reported by other studies (He, Liu & Chen, 2012). This study is
relevant to the research question and it helps to bridge the gap that addresses PU risk assessment
tool like Braden scale in acute care settings in long-term care. The study highlighted the
importance of nutrition and required intervention in the prevention of PU. The method used for
the study is case control study that is an epidemiological observational study highlighting the
long latency of PU risk in long-term care in acute settings. However, this kind of study is subject
to selection bias as in the study sample males were more than females. The sample data
collection is described in a representative manner. The study did not address the absolute risk of
PU and did not allow the scope for calculation of incidence of problem (Braden, 2012). The
sample size is small to study the effectiveness of Braden scale as sampling errors affect the
interpretation and precision of results. The validity of the instrument, Braden scale is discussed
thoroughly explaining the reliability and specificity of this tool and its use in PU risk assessment.
Voluntary response bias is a major drawback in case control study being a systematic error and it

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is difficult to identify the controls in the study (Brick, 2011). The findings of the paper showed
that Braden scale and its subscores provided maximum specificity and sensitivity (sensitivity
65%, specificity 70%) along with Braden subscores (sensitivity 80%, specificity 76%). The
overall performance of Braden scale for PU preventive interventions is not highlighted in the
article and requires proper analysis in the future. The aggregated risk from combined factors also
needs to be explored for future studies with an emphasis on each risk PU risk factor.
The paper by Gadd, (2012) studied the effectiveness of Braden scale, PU risk assessment
tool for hospital acquired PU (HAPU). The study design is a literature review that was conducted
to study the patients’ outcomes when this tool was used for HAPU assessment and discussed the
implications of future practice. The background of the study explicitly explained addressing the
issue of PU and foundation for patient safety. It also mentioned the wide use of Braden scale for
individualized planning based on subscale scores. According to Cohen et al., (2012) reviews
studied regarding the current use of this scale, concluded that Braden scale is the most robust,
and provide reliable data when compared to other risk assessment tools. Gadd, (2012), does not
explain this point in the article regarding reliability of Braden scale. The integrative literature
review used for this study comprised of only English language articles searched through
databases like MEDLINE, CINAHL and Cochrane Library. After reviewing 1825 articles, only
one article comprising of integrative literature search was studied. This is the major drawback of
this paper as the results are not sufficient and provide authenticity that can be generalized in a
population. The selected paper is a cohort study of PU risk factors that specifically discussed the
cumulative BS score to subscales. The paper by Cowen et al., (2012) did not address the above
mentioned point that is highlighted in this paper. The paper has highlighted the implications for
future practice where Braden subscale scores indicate need for individual interventions that is

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generally overlooked in patient-centred care. This paper mentioned that Braden scale is a reliable
tool, however, further evaluation of individual Braden subscores based on clinical judgment is
required that affect risk assessment and PU prevention.
The paper by Iranmanesh, Rafiei & Sabzevari, (2012) was a prospective descriptive study
where the purpose was to determine the relationship between Braden scale and PU development.
The study was significant as it studied that score obtained in Braden scale is inversely
proportional to PU risk. The main finding of the paper is that it is a useful tool for the prediction
of PU in trauma ICU patients. The paper also suggested other factors like age and consciousness
level that also influences the PU development. The study highlighted that PU risk is high in Iran
and nurses do not use any scale for the prediction of PU development and risk assessment.
Concisely, the study conducted is good and results indicated that Braden scale is a good predictor
for PU development among critically ill trauma patients in Iran. Based on the results obtained in
the study, the most significant difference between patients with or without PU was found in
sensory perception where they were able to responds meaningfully to pressure-related
discomfort. Other scales Waterlow, Norton and Cubbin-Jackson scale were used in patients for
high PU development risk for quality improvement in trauma ICUs (Chou et al., 2013). Mean
Braden score was 13·4 ± 3·5 as compared to Glasgow coma scale was 10·6 ± 3·7.
The paper by Tayyib, Coyer & Lewis, (2016) conducted a prospective cohort study
design for identification and PU risk incidence in ICU settings in Saudi Arabia. Out of 84
participants, over 33 participants were identified with new PUs of 39.3% (U=537⋅5, z=1098⋅5,
P=0.004). Lower Braden scale scores predicted the PU development higher as compared to other
studies (Gadd, 2014). The data collection method is not proper as it is limited by time. The study

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required a longer period and did not give any data regarding the frequency of repositioning
performed by nurses (Coleman et al., 2013). However, the study did not address the effectiveness
of Braden scale as compared to other scales like Waterlow or any description of development of
PU due to other factors like BMI or time of stay in emergency departments. The sample size was
small with a retrospective design and stage I PU exclusion. Small sample size suggests low
statistical power and false inferences about population (Button et al., 2013). This suggests a
research gap for prospective longitudinal studies confirming the association between PU and
those factors in ICUs. The study added information to the existing knowledge of PU incidence in
Saudi Arabia that suggests future studies for implementation of evidence-based practice for PU
prevention. The study strongly suggested that a comprehensive PU risk assessment and
prevention is required in ICUs in Saudi Arabia (VanDenKerkhof et al., 2011).
The study conducted by Tescher et al., (2012) was to identify the risk factors in PU and
enhancement of Braden scale use in the clinical settings. The study was a retrospective cohort
analysis of electronic medical records of 12,566 patients in Mayo Clinic was analyzed. In this
study, only iatrogenic stage 2 to 4 PUs were considered and excluded the stage 1 PU as the study
by Tayyib, Coyer & Lewis, (2016). The sample size comprised of 416 patients who developed
PU by using Braden scale that was found to be very predictive in PU development. This study
also provides an opportunity for enhancement of Braden subscales for the prevention of PU
specific for the patient. However, this study did not perform natural history study and data based
on active clinical practice (Teague et al., 2011). The effectiveness of these interventions might
have reduced the PU risk development. The factors like shear, friction or low nutrition status
might have influenced the results. The sample comprises of only high-risk population and its
impact in the general population and only at the time of admission, however, PUs are likely to

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develop with prolonged stay (Stern et al., 2011). The results showed that Braden scale subscales
are more predictive than Braden scale and provide scope for future studies that nurses should use
this scale for high alert risk assessment (P < .0001, C = 0.71) (C= 0.83).
Jaul & Menzel, (2014) also studied the use of Braden scale in the PU risk assessment and
highlighted the incidence of PU as a major complication among elderly population. The study
illustrated that there are severe complications associated with PU among the elderly. The
literature review is beautifully presented highlighting the prevalence of PU, pathogenesis and
prevention measures. The results of the study findings suggest that the use of Braden scale for
the risk assessment is superior in specificity and sensitivity as compared to other risk assessment
models like Waterlow and Norton scale. It is advantageous as it assess five risk factors; skin
moisture, sensory perception, mobility, activity levels, shearing forces, friction and nutritional
intake (Mallah, Nassar & Badr, 2015). Braden scale defines the risk level with maximum score
of 23, 18 or less indicate risk and score below 12 indicate high-risk patients (Eberlein-Gonska et
al., 2011). This study has not addressed the effectiveness of the scale in PU risk assessment that
does not align with the research question and its aims.
Implementation of evidence into nursing practice
The above evidence illustrates that clinical problem of PU is a major public health issue
that require urgent risk assessment and prevention. The above reviewed evidence shows that PU
is a clinical issue that is hampering patient safety within the healthcare settings and contribute to
the burden of disease and increased financial costs. Various risk factors contribute to pressure
ulcers and increase the risk for its development. There is a need to assess the risk at early stages
to prevent the development of PU from the time of admission. The key implications of the above

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reviewed evidence are that there is a need for wide use of risk assessment tools for the
prevention of PU and early PU risk identification. The findings also suggest that wide use of
Braden scale for risk assessment is not possible as it differ according to clinical setting and
varying healthcare systems. However, the findings of this systematic literature search are
significant and could be incorporated in the clinical setting with development of appropriate
interventions. The significant use of risk assessment scales would guide the clinical decisions
regarding evaluate of patient’s risk for PU development.
In nursing practice, clinical judgment is important to evaluate the score obtained by the
scales for identifying the risks for PU development (Mwebaza et al., 2013). For its incorporation
into clinical setting, a good understanding, knowledge is the key to identify the specific problem
of PU development guiding prevention strategies. The translation of the knowledge to clinical
practice is not possible as there are various barriers witnessed in the clinical setting of Saudi
Arabia (Bayoumi & Bassuni, 2016). The use of risk assessment tools, clinical judgment for
evaluation of obtained scale scores and provision for pressure relieving devices are important for
reducing the prevalence of PUs in the clinical settings. The above gathered evidence illustrates
that risk assessment by the nurses is helpful for identifying patients who are at high risk. The
above evidence depicts that Braden scale being the most widely used reliable tool for risk
assessment. The implications of the evidences is that there is a requirement for incorporation of
Braden scale use in the identification of PU risk in the clinical setting for ensuring patient safety.
For the implementation of Braden scale in the clinical setting in Saudi Arabia, many
barriers are identified. The findings showed that research gap is identified between scientific
evidence (best practice) and actual clinical practice. While reflecting on the implementation of
this practice in the clinical setting, a good understanding of the problem along with identification

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of the barriers and effective strategies are required. For implementation of change, there is lack
of awareness, agreement, self-efficacy, low expectancy, lack of motivation and external barriers
beyond the control that hinder the implementation for change in Saudi Arabia (Jankowski &
Nadzam, 2011). Bayoumi & Bassuni, (2016) studied the level of knowledge of Saudi Arabian
nurses regarding PU prevention measures. There is high prevalence of PUs in Saudi Arabia with
developing risk factors and nurses’ perceptions and knowledge regarding comprehensive skin
assessment and evaluation of results obtained from risk assessment tools is important for the
implementation of change in the clinical setting. Nurses have no conscious regarding the
assessment of scores obtained from risk assessment scales and factors for PU development vary
according to clinical settings where identified risk assessment tools may fail and there is a need
for new scales.
Lack of knowledge and clinical judgment is the major barrier, as results generated by the
risk assessment tools require critical thinking where nurses’ clinical judgment guides the
identification of PU risk in patients categorizing them as mild, moderate, high or no risk patients
for PU. The nurses’ clinical judgment for the determination of capacity of risk assessment scales
for the prediction of PU development is important for reducing the prevalence and prevention of
PUs (Sving et al., 2014).
Clinical judgment and accurate early skin assessment in pressure ulcers by the nurses are
the most effective strategies to implement change in Saudi Arabia. Although, clinical judgment
is important for evaluation o risk assessment scores, the specificity and sensitivity of the risk
assessment scales is not easy to validate alone with clinical judgment. When the clinical
judgment is used alone, it results in inadequate predictive capacity and so it is used in
combination with validated risk assessment scales like Braden scales. In addition, Braden scale

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also need to be used in combination with its subscales as it provides more accurate and specific
results. When they are used in combination, it provides more reliable and specific results in the
identification of PU risk factors and in reducing incidence of PU in the clinical settings. A study
conducted at Riyadh Military Hospital, Saudi Arabia demonstrated that Braden scale along with
nurses’ clinical judgment is used for identification of PU development that showed significant
results (Saleh, Anthony & Parboteeah, 2009). However, there were no significant results found
when Braden scale was used alone for PU incidence reduction and so, it is suggested that the
combination of Braden scale and clinical judgment of nurses can work together to improve
health outcomes regarding PU development. This phenomenon suggests that decrease in PU
prevalence may be an example of Hawthorn effect where increased awareness can benefit patient
care. It depicts that there is little difference between clinical judgment and Braden scale in terms
of dimensionality being the strongest predictors for PU risk assessment when used together
(Pickham et al., 2016).
The skin assessment, nutritional status for the pressure ulcer prevention is important for
the early detection of PU risk that can be helpful to understand the risk exposure. Early and
accurate skin assessment is also important for reducing the PU development and prevalence.
Comprehensive skin assessment is important where the skin is assessed for any abnormalities.
The identification of any PU, assistance in risk stratification for patients with existing pressures
is essential for identifying the risk for additional ulcers. The skin related factors or lesions that
predispose to PU development also need to be assessed for the patients who stay in bed or
wheelchairs for long hours in long-term care facilities. The assessment must include the five
parameters: temperature, colour, and moisture level, turgidity and skin integrity for any open

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areas or rashes. Nurses should perform standardized procedure for skin assessment by checking
the skin at the time of bathing, cleaning or repositioning (Engels et al., 2016).
Early risk assessment techniques need to be performed at equal intervals so that it
identifies people who are at risk for PUs. Nutritional level is also important as declining nutrition
can result in increased PU risk. Inadequate nutritional intake resulting in low body weight and
skin breakdown can result in increased risk for PU development. This suggests that nurses
should perform risk assessment using risk assessment tools like Braden scale to identify the
patients at high risk for PU development. Therefore, the compliance of the nurses towards the
validated risk management of pressure ulcer using Braden scale is important for the early
detection and management of the PUs (Sving et al., 2012).
Conclusion
From the above systematic literature review, it can be concluded that although Braden
scale is effective in the identification and assessment of risk for the PU detection and prevention,
Braden subscales increases the effectively of the assessment. When compared to other scales like
Waterlow, the evidences showed that Braden is a better reliable and effective tool with high
sensitivity and specificity. Braden scale is widely used in the clinical settings and its subscale
measures risk in six major categories: moisture, mobility, activity, sensory perception, nutrition,
and shear/friction. The score ranges from six to 23 where low score indicate high risk for PU
development and preventive interventions are developed accordingly. From the above findings, it
is clear that Braden scale alone cannot predict PU risk and require subscale or comparison with
other scales for the appropriate assessment of risk factors. Although, there is no single tool that
can assess risk with 100% specificity and sensitivity. However, certain barriers are identified that

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involved clinical judgment of the nurses and their compliance towards routine skin assessment
and identification of risk for PU prevention. The evidences gathered through systematic literature
search suggest that among the risk assessment tools, Braden scale is widely used as compared to
Waterlow or Norton scale. Among all, Braden suggested to have highest predictive validity and
nurses should know, understand, adopt and implement evidence based PU risk assessment tools
and standard PU protocols for prevention of PU. The evidences suggest that Braden scale cannot
be used alone and need to be used along with nurses’ clinical judgment for evaluating the results
obtained by scales.
Comprehensive skin assessment, moisture, nutritional status is also important for the
identification of patients who are at risk and reduce PU risk and prevalence. It also has
implications for future nursing practice where nurses have to be in position to provide early
intervention for reduction in prevalence and prevention of PU. In Saudi Arabia, for the
implementation of practice change in the clinical setting, there is a need for identification of
barriers and develop interventions to overcome it. Appropriate risk assessment through use of
risk assessment tools in the clinical setting is important for the early identification and
assessment of patients who are at risk for developing PU. Patient repositioning, use of foam
gels, nutritional assessment, adequate fluid intake, good skin care are some of the strategies can
be helpful in the implementation of change in Saudi Arabia clinical settings and in prevention of
PU and prevalence.

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23PRESSURE ULCER PREVENTION
Appendix
Sl. No. Author and Year
of Publication
study design and
sample/setting Major Findings
Strengths and
Limitations
1. Cowan et al., (2012) The paper is
qualitative in nature
and the study design
is case-control
study. This type is
an epidemiological
observation study
where Braden scores
and risk factors were
analysed in 213
acutely ill patients
with PU (n=100)
and without PU
(n=113) from
January to July
2008. The sample
setting is in Veterans
Health System
inpatient facility in
North Florida. The
patients having PU
(case) was compared
The findings of the
paper is that PU is
predicted in the
acutely ill veterans
by Braden scale
showing alone
sensitivity of 65%
and specificity 70%
in predicting the risk
assessment of
pressure ulcers. In
addition, the Braden
subscales also
showed better
results where
friction and activity
showed sensitivity
of 80% and
specificity of 76%
under the area ROC
curve 0.88. Braden
scale was identified
The case control study
design is an effective
method for the PU
prevention. The method
used is less time
consuming and is of
low cost. The results of
the study supported the
scientific literature
along with strong
Braden scale for the PU
risk assessment from all
predictive studies.
However, there are
limitations of the study
like data analysis where
the threat to validity of
findings were
underreported or not
captured in the
predictive model. The
preventive

24PRESSURE ULCER PREVENTION
to without PU acting
as controls in acute
care settings.
as an effective
predictor of PU risk
assessment in acute
care settings. This
scale provides
significant results, as
it is useful in the risk
assessment being a
strong predictive
tool. Braden scale is
used widely as
compared to
Waterlow and
Norton scale for the
PU risk assessment.
interventions during the
analysis were not
documented for the
subjects in this study.
2. Gadd, (2012) The paper is
qualitative in nature
with study design
used in this paper is
integrative literature
review and Medline
database was
searched along with
Cochrane, Google
Scholar and
CINAHL for
The major finding of
the paper is that
Braden subscale
scores is used for the
prevention of PU as
compared to
Waterlow and
Norton scale.
Braden scale is a
reliable and valid
predictor of risk
The strength of paper is
that the study selected
from the literature
search is helpful in the
identification of PU
risk in older adults as
compared to subscale
scores. Among the PU
risk assessment scales
for the predictive
validity, Braden scale

25PRESSURE ULCER PREVENTION
retrieving relevant
articles. After the
initial search of
1825 articles, 1
study was selected
that is a
retrospective cohort
study. Cochrane
library for searched
for the pressure
ulcers which met the
inclusion criteria
and allowed scope
for comparison of
PU risk assessment
tools.
assessment in PU in
acute care
populations.
was tested nine times as
compared to Norton
and Waterlow scales
that predicted Braden
scale as one of the
reliable PU assessment
scale. This study has
certain limitation. After
the literature serach,
only one study was
included that observed
the Braden scale
effectiveness in the PU
risk assessment. The
study did not focus on
the Braden scale
subscores for guiding
the preventive
interventions
implementation.
3. Iranmanesh, Rafiei &
Sabzevari, (2012)
The study is
quantitative in
nature where
descriptive-
prospective study
was applied to study
The major finding of
the paper is that
Braden scale is a
reliable and useful
tool for the
prediction of PU
The strength of the
paper is that the study
found that Iranian
critical care nurses do
not use any predictive
PU scale and only

26PRESSURE ULCER PREVENTION
the relationship
between pressure
ulcer development
and Braden scale
among trauma
patients in ICU. The
study setting was
Shahid Bahonar
Hospital in
Kerman. The sample
for the study
included 82 patients
who were admitted
in ICU during July
to October 2010 in 3
months.
development in
trauma ICU patients.
The scoring on
Braden scale is
inversely
proportional as high
score indicate low
risk for PU
development and
also suggested that
level of
consciousness and
age may influence
PU development.
perform skin care for
patients with different
PU risk. The findings
of the paper inclined
with the study aim as
Braden scale proved to
be a useful tool for the
PU risk assessment.
Although, other scales
like Waterlow, Norton
and Cubbin-Jackson
scales were suggested,
however, it was used
for the prediction of PU
development among
high-risk patients.
4. Tayyib, Coyer &
Lewis, (2016)
The paper is
quantitative in
nature where the
incidence and risk of
PU was studied
among the patients
in two adult ICUs in
Saudi Arabia. The
study design is a
multicentre
The major finding of
the paper is that
Braden scores were
low that indicated
high risk of PU
among the ICU
patients with an
incidence of 39.3%
that is hospital
acquired. There was
The strength is that it is
the first study that
provided a baseline
data on the incidence of
PU in ICUs, Saudi
Arabia that was not
established before. The
study also reported the
high incidence of
hospital acquired PUs

27PRESSURE ULCER PREVENTION
prospective
observational cohort
study carried out in
two tertiary major
care hospitals in
Saudi Arabia
between July and
August 2013. The
sample is collected
from 84 ICU
patients out of 90
patients during 30-
day study period
who are above 18
years of age and
data extraction form
was used for the
cohort study. The
data collection
processes were
validated through
instruments that
included Braden
Scale
score (24), PU-
staging scales (7)
infrequent
positioning, long
hospital stays, and
mechanical
ventilation predicted
the PU development
in ICU patients. The
data presented in the
paper provided
baseline ICU
incidence rates in
Saudi Arabia is high
that added
significant
information in this
field. Braden scale
was used to measure
the incidence of PU
and in risk
assessment. The
study findings
suggested that no
baseline data existed
in Saudi Arabia on
PU incidence in
ICU. Braden scale
in Saudi Arabia
(39.3%). The research
also provided a
benchmark for studying
the incidence and risk
factors of PU in Saudi
Arabia and compared to
other international
studies. However, this
paper has certain
limitations. The time
period for data
collection is less and
there was no data
reported regarding the
frequency of
repositioning of
patients. Repositioning
of patients were
recorded from patient
notes retrospectively.
The data did not
comprise of the
information on care
processes and therefore,
there was missing

28PRESSURE ULCER PREVENTION
and Sequential
Organ Failure
Assessment (SOFA)
score (23).
was used as an
excellent risk
assessment tool for
PU along with
Sequential
Organ Failure
Assessment (SOFA)
score and PU
staging. However,
Braden scale was
considered to be a
reliable tool for the
risk assessment for
PU prevention.
report on adherence of
hospitals to policies.
5. Tescher et al., (2012) The study design is
quantitative in
nature that is a
retrospective cohort
analysis of EMRs
from January to
December 2007. The
sample comprised of
12,566 adult patients
in ICUs within
Mayo Clinic.
Inclusion criteria
The major finding of
the paper is that
Braden scale is a
strong predictor of
PU development.
Braden subscales
also enhance
prevention programs
that focused on risk
assessment and
factors that is
individualized to the
The strength of the
paper is that Braden
scales subscales were
found to be highly
predictive in the
development of PU
along with Braden scale
score alone. Risk alert
is also predicted by this
study that nurses should
consider both Braden
scale and subscales for