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Continuing Education

HOURS

By Nancy A. Stotts, EdD, RN, FAAN, and Lena Gunningberg, PhD, RN

Predicting

Pressure Ulcer Risk

Using the Braden scale with hospitalized older adults: the evidence supports it.

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Web Video
Overview: Pressure ulcers are a serious concern in caring for older adults in all settings. In addition to being painful and expensive to treat, they can significantly compromise a patients mental, emotional, and social wellbeing. The Braden Scale for Predicting Pressure Sore Risk assesses a patients risk of developing these ulcers so that those judged to be at risk can receive preventive care. The scale consists of six subscales and can be completed in just one minute. (This screening tool is included in a series, Try This: Best Practices in Nursing Care to Older Adults, from the Hartford Institute for Geriatric Nursing at New York Universitys College of Nursing.) For a free online video demonstrating the use of this tool, go to http:/ /links.lww.com/A106. Watch a video demonstrating the use and interpretation of the Braden scale at http:// links.lww.com/A106.

A Closer Look
Get more information about pressure ulcer risk and assessment in older adults.

Try This: Predicting Pressure Ulcer Risk

This is the Try This tool in its original form. See page 45.

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Unique online material is available for this article. Direct URL citations appear in the printed text; simply type the URL into any Web browser.

ighty-six-year-old Fred Adams was hit by a car as he crossed the intersection near his house. (This case is a composite based on the authors experiences.) Transported by ambulance to the ED of a nearby hospital, he arrives with a blood pressure reading of 134/84 mmHg; heart rate, 92 beats per minute; respirations, 20 breaths per minute; and temperature, 36.2C (97.2F). He is alert and oriented and able to describe what happened: a woman driving a small car failed to see him as she made a left turn into the intersection, knocking him over and rolling him onto the sidewalk. Mr. Adams reports that he has hypertension, which is controlled with hydrochlorothiazide (HydroDIURIL and others) 12.5 mg per day. On examination his cranial nerve function is within normal limits. Motion and sensation are present in all extremities, although motion in his left leg is limited and painful because of an injury to his left hip. He does not want to be moved or have his hip or leg touched. Admission data indicate that he lives alone, drives his own car, and manages his household independently. After an X-ray confirms a fracture of the left hip in the intertrochanteric region, Mr. Adams is transferred immediately to surgery for internal fixation of the joint. After postoperative admission to the

orthopedic unit, he is evaluated with the Braden Scale for Predicting Pressure Sore Risk. WHY USE THE BRADEN SCALE? The Braden Scale for Predicting Pressure Sore Risk was developed to help nurses determine patients risk of developing pressure ulcers. The scale, which takes less than a minute to complete, has been used with patients of all ages and in all settings and has been found to be more accurate than other scales (including the Norton and the Waterlow scales) or clinical judgment.1 While its use alone does not prevent pressure ulcers, its findings are the sentinel that calls nurses to employ preventive strategies. For information on preventing pressure ulcers and using guidelines, go to http://links.lww.com/A183. It was developed in the 1980s by nurses Barbara Braden and Nancy Bergstrom, who established that the critical determinants of pressure ulcer development are2: 1. the intensity and duration of pressure 2. the ability of the skin and supporting tissues to tolerate pressure They also described the factors influencing these two determinants. Mobility, activity, and sensory perception contribute to the intensity and duration
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o to http//links.lww.com/A106 to watch a nurse use the Braden scale in an actual patient and discuss how to administer and interpret it quickly. Then watch the health care team plan preventive strategies. View this video in its entirety and then apply for CE credit at www.nursingcenter.com/AJNolderadults; click on the How to Try This series link. All videos are free and in a downloadable format (not streaming video) that requires Windows Media Player.

of pressure. Tissue tolerance is influenced by both extrinsic factors (moisture, friction, and shear) and intrinsic factors (nutrition, age, and arterial pressure). Six of these factors became the subscales of the Braden scale. (See Why Assess Pressure Ulcer Risk? page 43.) sensory perception activity mobility skin moisture nutritional intake friction and shear ADMINISTERING THE BRADEN SCALE The patient is evaluated on each of the six subscales, with the scoring based on the descriptions provided in the tool (see Try This, page 45). The nurse uses physical assessment and interviewing to elicit the data to complete the Braden scale. Scores for the levels of risk within each subscale range from 1 to 4, with the exception of friction and shear, which is scored from 1 to 3. Each subscale includes a title; within the subscale, each level has a key concept description and one or two phrases or sentences describing its qualifying attributes. For example, in the subscale activity, the lowest score1is given when a patient is bedfast, followed by a 2 for one who is chairfast, a 3 for a patient who walks occasionally, and a 4 for one who walks frequently. Item descriptors determine the patients score. For example, in order to score a 4 in the activity subscale, the patient must walk outside [the] room at least twice a day and inside [the] room at least once every two hours during waking hours, according to the scale. Its important not to alter the scale by adding or deleting items or by modifying existing definitions; any such change will result in inaccuracy.12 The final scoreobtained by totaling the scores from the six subscalesranges from 6 to 23. To view the segment of the online video showing a nurse completing the Braden scale, go to http://links.lww.com/A107.
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The Wound, Ostomy, and Continence Nurses Society (WOCN) recommends that all patients in acute, long-term, and home care be assessed for risk of pressure ulcers at the time of admission. Mr. Adams. Upon entering Mr. Adamss room, his nurse introduces herself and begins the assessment. Im Frances Cornell, and Im the nurse caring for you today, she says. I need to ask you some questions, some of which may seem silly. But can you tell me who you are, where you are, and what the date is? Mr. Adamss answers confirm that he is alert and oriented to time, place, and person. Next she asks, Are you having pain? How would you describe it on a scale of 0 to 10, where 0 is no pain and 10 is the worst pain imaginable? Mr. Adams says that his pain is an 8. Taking both of these answers into account, she records a score of 4, meaning no impairment, on the sensory perception subscale. This subscale measures the ability to respond meaningfully to pressure-related discomfort by looking at both the patients perception of pain and her or his level of consciousness. Mr. Adams is perspiring heavily, probably because of his pain. The nurse finds no evidence of incontinence or wound drainage, so she assigns a score of 3, occasionally moist, on the moisture subscale. Ms. Cornell checks the incision and makes sure the hip-abduction pillow is securely in place. As she settles him in, she notes that he is on bed rest today and gives him a score of 1, bedfast, on the activity subscale. He can make slight changes in position, but as is to be expected with this type of injury, he cant change position independently. His mobility is very limited, and he receives a 2 on this subscale. Because he requires assistance to move, he also scores a 2, potential problem, on the friction and shear subscale. Ms. Cornell asks for specific information on his nutritional status, noting that he reported in the ED that he lives alone and does his own shopping and cooking. How would you describe your eating yesterday? she asks. Coffee and a banana for breakfast, he answers. I wasnt very hungry at noon so I had cold cereal with milk. For dinner, I had a can of mushroom soup. I thought about having toast with it but I just wasnt that hungry. Later, I had two chocolate chip cookies for a snack. Although Mr. Adamss body mass index (BMI) is in the normal range, his intake the previous day was insufficient. Since being hospitalized, he has taken limited liquids, has received intravenous crystalloid fluids, and has had no nutrition since his surgery. The nurse anticipates that it will take a few
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Why Assess Pressure Ulcer Risk?

The importance of avoiding pressure ulcers.

ressure ulcers are a significant problem in hospitalized older adults. In the United States, Canada, and parts of Europe, prevalence ranges from 14% to 25% and incidence from 7% to 9%.3-5 One study found a slightly lower incidence (6.2%) when older adults were assessed for risk early in the hospital stay.6 Research shows that pressure ulcers and their treatment negatively affect every dimension of a patients life: emotional, mental, physical, and social.7 Patients in one study reported experiencing endless pain, and those in another said that nursing staff didnt acknowledge or treat their discomfort and pain (although they received many pressure ulcerrelated interventions).7, 8 Even usual nursing care, such as turning, has been found to be painful for patients with pressure ulcers.8, 9

Pressure ulcers are also expensive to treat. Beckrich and Aronovich estimated in 1999 that the annual cost of hospital-acquired pressure ulcers was $2.2 billion to $3.6 billion.10 Costs vary by the severity of the ulcer, its location, and the goals of treatment, but they may include the nursing time required to treat ulcers and turn and position patients; pressure-relieving devices (mattresses, cushions); dressings, antibiotics, and surgical treatment (such as debridement); and physicians fees. Other expenses include hospital and nursing home room fees and additional hospitalization for people who develop ulcers while hospitalized for another condition.11 To view the segment of the online video discussing Braden scale scores, go to http:/ /links.lww.com/ A109.

days for him to reach adequate intake. Thus, he receives a score of 1, very poor, on the nutrition subscale. Challenges that may arise. Because the sensory perception subscale includes two areas for assessmentthe patients level of consciousness and his perception of pain (see the scale on page 46)the lower of the two scores should be assigned. For example, a patient who has had a stroke and is alert (a 4 on the subscale) but has sensory deficits in a single limb because of disease (a 3) should receive a score of 3 for the subscale. It can be challenging to complete an accurate evaluation for the nutrition subscale. This subscale scores usual intake and is applicable to eating as well as to feeding methods such as ivs, total parenteral nutrition, or tube feeding. Assessment of oral intake requires knowledge of the patients eating patterns, so data must be gathered over several days. If a patient is nonresponsive upon admission and family or friends cannot report on intake, nutritional status can be evaluated using BMI and serum albumin level; the assessment will also take into account current plans for the patients nutrition (for example, if the patient has an injury that will prohibit intake or she or he is to take nothing by mouth for several days for tests or treatments). Clinical judgment is used to assign a score. The rule of thumb is to do no harm, so if the data are borderline, assign a lower risk score. Similarly, because it often takes several days for tube feeding target goals to be reached, the patient may be underfed. In this case, a score of 2 should be assigned because the patient is receiving less than [the] optimum amount of liquid diet or tube feeding.
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SCORING AND INTERPRETING RESULTS Levels of risk have been defined as the following categories of scores13: 19 to 23: not at risk 15 to 18: at risk 13 to 14: at moderate risk 10 to 12: at high risk 6 to 9: at very high risk Lower scores suggest higher risk and require more aggressive preventive efforts.12 Care for those with a score of 19 or higher can proceed without special attention to pressure ulcer risk. The Braden scales characterization of pressure ulcer risk as a numerical value makes a change in status easy to identify and act upon. To view the segment of the online video discussing Braden scale scores, go to http://links.lww.com/A109. Mr. Adamss Braden scale score upon admission was 13 out of 23, indicating a moderate risk of pressure ulcers. Of foremost concern were his results on the activity, mobility, and friction and shear subscales; his scores on the nutrition and moisture subscales also indicated possible risk. Following the hospitals protocol, a nurse evaluates Mr. Adamss skin at all major pressure points: heels, ankles, sacrum, ischial tuberosities, the trochanteric area, elbows, shoulder blades, spine, and the back of the head. She documents the status of his surgical incision. His skin is intact and there are no areas of redness over bony prominences. Special care is taken to assess his heels and sacrum, which are the most common sites of pressure ulcers.14 Mr. Adams is particularly susceptible to damage in these areas because he will be spending considerable time in the supine position, and he will be using the heel of his good leg to help him turn
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and use the bedpan. Both of his heels are suspended above the bed with pillows under the calves. The hospital recently replaced all of its mattresses with pressure-relieving mattresses. In hospitals that have older mattresses, a mattress overlay or a low air loss mattress can be used, although some data indicate positive outcomes for hip fracture patients for whom a pressure reducing overlay or mattress is not routinely used in postoperative care.15 The nurse writes a plan of care that incorporates pressure ulcer prevention. To make sure Mr. Adams is repositioned regularly, two cues are used in the room. A navy blue sticker is attached to the white board at the foot of his bed (where daily activities are listed), which reminds the staff to keep the head of the bed at 30 or lower, except at mealtimes. Also, a clock-shaped repositioning schedule is posted on the board to serve as a reminder of when and how Mr. Adams should be repositioned. In addition, every two hours the overhead paging system plays a four-note jingle to remind the staff that its time to turn patients. The nurse also asks the dietitian to perform a routine nutritional evaluation to ensure that Mr. Adams is taking in enough calories, protein, and fluids. His blood will be drawn for laboratory analysis of total protein, albumin, and prealbumin levels, which will help determine whether nutritional supplementation is needed. Daily Braden scale scoring and skin reassessment will indicate whether Mr. Adamss plan of care should be modified. Reassessment schedules are set by the health care facility, according to the nature of its population. Reassessment is recommended when a patients condition changes, as well as at regular intervals.16-18 In home care, reassessment at each visit is recommended.17 There is some disagreement, however, on how often reassessment should be done in hospitals and long-term care facilities. In hospitals, the Institute for Healthcare Improvement recommends daily reassessment,16 while the WOCN recommends reassessment every 48 hours.17 For patients in long-term care, the WOCN recommends weekly assessment for four weeks and then quarterly,17 while the American Medical Directors Association recommends that high-risk patients be reassessed quarterly.18 OTHER CONSIDERATIONS Differences between nurses or patients cultures are unlikely to affect the accuracy of the Braden scale since there is little in the scale that asks for interpretation of meaning or symbols. On the other hand, a patients skin tone can affect a nurses ability to detect pressure ulcers. Risk assessment with the Braden scale has been examined in different racial
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groups. For example, Bergstrom and Braden compared cutoff scores (the number at or below which the patient is considered at risk) for black and white patients and found that the cutoff score of 18 best predicts risk for both groups.19 Lyder and colleagues explored pressure ulcer prediction with the Braden scale in black and Hispanic patients and found that a cutoff score of 18 was valid for predicting pressure ulcer risk in black patients ages 75 years and older.20 Translations of the Braden scale are available in Chinese, Japanese, Dutch, French, German, Italian, Portuguese, and Swedish.5, 21, 22 COMMUNICATING THE RESULTS Because patients are a part of the health care team, they should be apprised of their pressure ulcer risk status. Its important also to give them an overview and explanation of the prevention plan. With the patients approval, family members may also be apprised of this information and enlisted to help with prevention efforts. The patients permanent record is used to communicate pressure ulcer risk to other health care professionals; report at change of shift is also important. Various bedside strategies used to alert staff to a patients increased pressure ulcer risk include putting a sticker denoting risk on the white board at the foot of the patients bed and posting a turning schedule near the bed (for sample schedules see www.bradenscale.com/turning.htm). The video segment demonstrating how to communicate the results of the Braden scale assessment in preparation for discharge is available at http://links.lww.com/A110. Mr. Adams. Ms. Cornell tells Mr. Adams that her assessment suggests hes at risk for pressure ulcers and explains why thats an important concern. She discusses the hazards of being immobile with Mr. Adams and his younger sister, Jane Diehl, who is visiting him in his hospital room. She explains that Mr. Adams is at risk for pressure ulcers because of his fracture and its treatment, and she describes the preventive care that has been implemented. She asks them to help with turning and positioning and fluid intake when possible. Mr. Adams, you can help the nurse position you when youre turned every two hours. Also, if you find that two hours have gone by and you havent been turned, or if you need help between the scheduled turns, please let us know. Ms. Diehl, if you come in and see that its time for him to be turned, dont hesitate to ask one of the staff to reposition him. Mr. Adams, we also want you to drink a lot of liquids to stay well hydrated, so well try to leave your water pitcher within your reach. If we forget, please remind us.
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Issue Number 5, Revised 2007 Series Editor: Marie Boltz, PhD, APRN, BC, GNP Managing Editor: Sherry A. Greenberg, MSN, APRN, BC, GNP New York University College of Nursing

Predicting Pressure Ulcer Risk

By: Elizabeth A. Ayello, PhD, APRN, BC, CWOCN, FAPWCA, FAAN Excelsior College School of Nursing
WHY: Pressure ulcers (PUs) occur frequently in hospitalized, community-dwelling and nursing home older adults, and are serious problems that can lead to sepsis or death. Prevalence of PUs ranges from 10-17% in acute care, 0-29% in home care, and 2.3-28%in institutional long-term care (LTC); incidence ranges from 0.4-38% in acute care, 0-17% in home care, and 2.2-23.9% in institutional LTC. A key to prevention is early detection of at risk patients with a valid and reliable PU risk assessment instrument and timely interventions. BEST TOOL: The Braden Scale for Predicting Pressure Sore Risk is among the most widely used tools for predicting the development of PUs. Assessing risk in six areas (sensory perception, skin moisture, activity, mobility, nutrition and friction/shear), the Braden Scale assigns an item score ranging from one (highly impaired) to three/four (no impairment). Summing risk items yields a total overall risk, ranging from 6-23. If a patient has major risk factors such as fever, diastolic pressure below 60, hemodynamic instability, advanced age, then move them to the next level of risk. Scores 15 to 18 indicate at risk, 13 to 14 indicate moderate risk, 10 to 12 indicate high risk, 9 indicate very high risk. In addition to assessing total overall risk, basing prevention protocols on low sub-scores are required by Centers for Medicare and Medicaid Centers in the revised Tag F 314 for long term care. Targeting specic prevention interventions that address low risk sub-scores can offer effective resource use. TARGET POPULATION: The Braden Scale is commonly used with medically and cognitively impaired older adults. It has been used extensively in acute, home, and institutional LTC settings. New PUs are more common in the rst two weeks of admission to a hospital or LTC. Recommendations for assessment are on admission or when the patients condition changes (including cognition or functional ability) and at the following intervals: acute care-every 48 hours; critical care-every 24 hours; home care-every RN visit; institutional LTC-weekly rst 4 weeks after admission, monthly to quarterly. VALIDITY AND RELIABILITY: The ability of the Braden Scale to predict the development of PUs (predictive validity) has been tested extensively. Inter-rater reliability between .83 and .99 is reported. The tool has been shown to be equally reliable with Black and White patients. Sensitivity ranges from 83-100% and specicity 64-90% depending on the cut-off score used for predicting PU risk. A cut-off score of 18 should be used for identifying Black and White patients at risk for pressure ulcers. STRENGTHS AND LIMITATIONS: When utilized correctly and consistently, the Braden Scale will help identify the associated risk for PU so that appropriate preventive interventions can be implemented. Although the Braden Scale has been used primarily with White older adults, research addressing Braden Scale efcacy in Black and Latino populations suggests that a cut-off score of 18 or less prevents under-prediction of PU risk in these populations. MORE ON THE TOPIC:
Best practice information on care of older adults: www.ConsultGeriRN.org. Ayello, E.A., & Braden, B. (2002). How and why to do pressure ulcer risk assessment. Advances in Skin and Wound Care, 15(3), 125-132. Baranoski, S., & Ayello, E.A. (2004). Wound care essentials: Practice principles. Springhouse PA: Lippincott Williams & Wilkins. Bergstrom, N., & Braden, B.J. (2002). Predictive validity of the Braden Scale among Black and White subjects. Nursing Research, 51(6), 398-403. Bergstrom, N., Braden, B.J., Laguzza, A., & Holman, V. (1987). The Braden Scale for predicting pressure sore risk. Nursing Research, 36(4), 205-210. Braden Scale. http://www.bradenscale.com. Last accessed June 27, 2007. Center for Medicare and Medicaid Services (CMS) Tag F 314 Pressure Ulcers Guidance for Surveyors in Long Term Care. Last accessed August 9, 2006 from http://new.cms.hhs.gov/manuals/downloads/som107ap_pp_guidelines_ltcf.pdf Cuddigan, J., Ayello, E.A., & Sussman, C. (2001). Pressure ulcers in America: Prevalence, incidence & indications for the future. Reston VA: NPUAP (National Pressure Ulcer Advisory Panel). Lyder, C.H., Yu, C., Stevenson, D., Mangat, R., Empleo-Frazier, O., Emrling, J., & McKay, J. (1998). Validating the Braden Scale for the prediction of pressure ulcer risk in Blacks and Latino/Hispanic elders: A pilot study. Ostomy/Wound Management, 44(3A), Suppl: 42S-50S. U.S. Department of Health and Human Services, Agency for Health Care Research and Quality. (1992). Pressure ulcers in adults: Prediction and prevention (AHCPR Publication No. 92-0047). Rockville, MD: Author.

Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for not-for-prot educational purposes only, provided that The Hartford Institute for Geriatric Nursing, College of Nursing, New York University is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the internet at www.hartfordign.org and/or www.ConsultGeriRN.org. E-mail notication of usage to: hartford.ign@nyu.edu.

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Online Resources
And Ms. Diehl, feel free to help place it within his reach and to bring him some special liquids that he might like. They also discuss the importance of daily skin evaluation and reevaluation with the Braden scale. Mr. Adamss postoperative course is uneventful. The pressure ulcer prevention plan is successful, with the staff consistently implementing the plan and reassessing him with the Braden scale daily. During his seven-day hospital stay, his situation improves and he is mobilized, his pain is controlled, and his nutritional intake improves; ultimately, he is discharged with his skin intact. He follows his hospital stay with 20 days at a nearby skilled nursing facility, where additional physical therapy enables him to resume his independent life. To view the segment of the online video on use of the tool as a continuous quality improvement intervention, go to http://links.lww.com/A108. CONSIDER THIS The widely used Braden Scale for Predicting Pressure Sore Risk is regarded as the best tool for identifying pressure ulcer risk and indicating the need for preventive measures. Here are some additional considerations. What evidence supports relying on the Braden scale to identify patients at risk for pressure ulcer? The Braden scale has been widely studied to determine whether it predicts pressure ulcer risk. Early studies established its value.21, 23, 24 Although rigorously conducted, these studies were done when pressure ulcer prevention was not a standard part of nursing care. As pressure ulcer prevention has become routine in hospital care, study results have changed. Today when a prevalence study is conducted, it measures the number of people who have pressure ulcers with some pressure ulcer prevention having been undertaken. Thus, the ability of the Braden scale to accurately predict who will develop pressure ulcers cannot be assessed as purely as before. Nevertheless, the available research indicates that it does a good job of predicting ulcer development and can be relied upon in clinical settings. (For more information on interpreting psychometric aspects of tools, see Define Your Terms, October.) Reliability. The Braden scale has high (r = 0.99) interrater reliability among RNs on medical surgical and critical care step-down units.2 Validity. The Braden scale has demonstrated strong predictive validity, meaning that it effectively predicts the development of pressure ulcers. For example, in one study that used a cutoff score of 16 in 60 critical care patients, researchers found that the scales positive predictive validity (correctly predicting that a pressure ulcer would occur) was 61% and its negative predictive validajn@wolterskluwer.com

or more information on the Braden Scale for Predicting Pressure Sore Risk and additional resources, including a video for training staff on its use and competency tests, go to www.bradenscale.com. The Braden Scale is protected by copyright. Permission can be obtained, usually free of charge, for patient settings at this web site. For other geriatric assessment tools and best practices, go to www.hartfordign.org, the Web site of the John A. Hartford Foundationfunded Hartford Institute for Geriatric Nursing at New York University College of Nursing. The institute focuses on improving the quality of care provided to older adults by promoting excellence in geriatric nursing practice, education, research, and policy. Download the original Try This document on the Braden Scale for Predicting Pressure Sore Risk by going to www.hartfordign. org/publications/trythis/issue05.pdf. For more information on best practices in the care of older adults go to www.ConsultGeriRN.org. The site lists many related resources and offers continuing education opportunities. Go to www.nursingcenter.com/AJNolderadults and click on the How to Try This link to access all articles and videos in this series.

ity (correctly predicting that a pressure ulcer would not occur) was 86%.23 r Sensitivity. In a systematic review of 33 studies, researchers concluded that the Braden scales sensitivityits ability to identify those at risk for pressure ulcershas been extensively validated and is reasonably good (57.1%).1 r Specificity. The same review found that the Braden scale has reasonably good specificity (67.5%), indicating that nurses can be fairly confident that the scale will accurately determine that someone with a high score is not at risk for developing a pressure ulcer.1 For a more complete discussion of the studies on the psychometric properties of the Braden scale, go w to http://links.lww.com/A182.
Nancy A. Stotts is a professor at the School of Nursing, University of California, San Francisco, where she is associate director of the John A. Hartford Center of Geriatric Nursing Excellence. Lena Gunningberg is an assistant professor and leader of the Department of Nursing Research and Development, Surgery Division, at Uppsala University Hospital, Sweden. Contact author: Nancy Stotts, nancy.stotts@nursing.ucsf.edu. The authors have no significant ties, financial or otherwise, to any company that might have an interest in the publication of this educational activity. How to Try This is a three-year project funded by a grant from the John A. Hartford Foundation to the Hartford Institute for Geriatric Nursing at New York Universitys College of Nursing in collaboration with AJN. This initiative promotes the Hartford Institutes geriatric assessment tools, Try This: Best Practices in Nursing Care to Older Adults: www.hartfordign.org/trythis. The series will include articles and corresponding videos, all of which will be available for free online at www.nursingcenter.com/ AJNolderadults. Stotts and Sherry A. Greenberg, MSN, APRN,BC, GNP (sherry@familygreenberg.com), are coeditors of the print series. The articles and videos are to be used for educational purposes only. Routine use of a Try This tool may require formal review and approval by your employer.

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REFERENCES
1. Pancorbo-Hidalgo PL, et al. Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs 2006; 54(1):94-110. 2. Bergstrom N, et al. The Braden Scale for Predicting Pressure Sore Risk. Nurs Res 1987;36(4):205-10. 3. Whittington KT, Briones R. National Prevalence and Incidence Study: six-year sequential acute care data. Adv Skin Wound Care 2004;17(9):490-4. 4. Woodbury MG, Houghton PE. Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy Wound Manage 2004;50(10):22-38. 5. Vanderwee K, et al. Pressure ulcer prevalence in Europe: a pilot study. J Eval Clin Pract 2007;13(2):227-35. 6. Baumgarten M, et al. Pressure ulcers among elderly patients early in the hospital stay. J Gerontol A Biol Sci Med Sci 2006;61(7):749-54. 7. Spilsbury K, et al. Pressure ulcers and their treatment and effects on quality of life: hospital inpatient perspectives. J Adv Nurs 2007;57(5):494-504. 8. Hopkins A, et al. Patient stories of living with a pressure ulcer. J Adv Nurs 2006;56(4):345-53. 9. Rastinehad D. Pressure ulcer pain. J Wound Ostomy Continence Nurs 2006;33(3):252-7. 10. Beckrich K, Aronovitch SA. Hospital-acquired pressure ulcers: a comparison of costs in medical vs. surgical patients. Nurs Econ 1999;17(5):263-71. 11. Javitz HS, et al. Major costs associated with pressure sores. J Wound Care 1998;7(6):286-90. 12. Ayello EA, Braden B. How and why to do pressure ulcer risk assessment. Adv Skin Wound Care 2002;15(3):125-31. 13. Braden BJ, Maklebust J. Preventing pressure ulcers with the Braden scale: an update on this easy-to-use tool that assesses a patients risk. Am J Nurs 2005;105(6):70-2. 14. Cuddigan JG, et al. Pressure ulcers in America: prevalence, incidence, and implications for the future. Reston, VA: National Pressure Ulcer Advisory Panel; 2001. 15. Beaupre LA, et al. Reduced morbidity for elderly patients with a hip fracture after implementation of a perioperative evidence-based clinical pathway. Qual Saf Health Care 2006; 15(5):375-9. 16. Institute for Healthcare Improvement. Five million lives campaign. Prevent pressure ulcers: getting started kit. 2006. http:// www.ihi.org/IHI/Programs/Campaign/ PressureUlcers.htm. 17. Wound, Ostomy, and Continence Nurses Society. Guideline for the prevention and management of pressure ulcers. Mount Laurel, NJ; 2002. Report 000-2002. 18. American Medical Directors Association. Pressure ulcers [Clinical Practice Guideline]. Columbia, MD; 1996. CPG2. 19. Bergstrom N, Braden BJ. Predictive validity of the Braden Scale among Black and White subjects. Nurs Res 2002;51(6): 398-403. 20. Lyder CH, et al. Validating the Braden Scale for the prediction of pressure ulcer risk in blacks and Latino/Hispanic elders: a pilot study. Ostomy Wound Manage 1998;44(3A Suppl): 42S-49S. 21. Bergstrom N, et al. Using a research-based assessment scale in clinical practice. Nurs Clin North Am 1995;30(3):53951. 22. Torra i Bou JE. [Evaluating the risks of pressure ulcers. The Braden scale]. Rev Enferm 1997;20(224):22-30. 23. Bergstrom N, et al. A clinical trial of the Braden Scale for Predicting Pressure Sore Risk. Nurs Clin North Am 1987; 22(2):417-28.

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present the background information essential for understanding the need for and the development and use of the Braden scale. plan the essential steps for determining a patients Braden score and intervening accordingly. outline the information relevant to the use of the Braden scale and its subscales.

TEST INSTRUCTIONS To take the test online, go to our secure Web site at www. nursingcenter.com/CE/ajn. To use the form provided in this issue,
record your answers in the test answer section of the CE enrollment form between pages 48 and 49. Each question has only one correct answer. You may make copies of the form. complete the registration information and course evaluation. Mail the completed enrollment form and registration fee of $19.95 to Lippincott Williams and Wilkins CE Group, 2710 Yorktowne Blvd., Brick, NJ 08723, by November 30, 2009. You will receive your certificate in four to six weeks. For faster service, include a fax number and we will fax your certificate within two business days of receiving your enrollment form. You will receive your CE certificate of earned contact hours and an answer key to review your results. There is no minimum passing grade.

DISCOUNTS and CUSTOMER SERVICE

Send two or more tests in any nursing journal published by Lippincott Williams and Wilkins (LWW) together, and deduct $0.95 from the price of each test. We also offer CE accounts for hospitals and other health care facilities online at www.nursingcenter.com. Call (800) 787-8985 for details.

PROVIDER ACCREDITATION
LWW, publisher of AJN, will award 2 contact hours for this continuing nursing education activity. LWW is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation. LWW is also an approved provider of continuing nursing education by the American Association of CriticalCare Nurses #00012278 (CERP category A), District of Columbia, Florida #FBN2454, and Iowa #75. LWW home study activities are classified for Texas nursing continuing education requirements as Type 1. This activity is also provider approved by the California Board of Registered Nursing, provider number CEP 11749, for 2 contact hours. Your certificate is valid in all states.

TEST CODE: AJNTT03

http://www.nursingcenter.com

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AJN w November 2007

Vol. 107, No. 11