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Braden Scale (Pressure Ulcer)

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Purpose

The BS assesses the likelihood of developing pressure ulcers.

Link to Instrument

Instrument Details

Acronym BS

Area of Assessment

General Health

Assessment Type

Observer

Administration Mode

Paper & Pencil

Cost

Free

Cost Description

For permission refer to http://www.bradenscale.com/

Diagnosis/Conditions

  • Brain Injury
  • Spinal Cord Injury
  • Stroke Recovery

Key Descriptions

  • Braden total scores range from 6 to 23 points with lower scores indicating a higher risk for presses ulcers.
  • Braden scale subscales include:
    1) Sensory subscale to measure the ability to feel and relieve discomfort
    2) Moister subscale to assess the degree to which skin is exposed to moisture
    3) Mobility subscale to assess one's ability to relieve pressure
    4) Activity subscale to assess the ability to get out of bed and/or ambulate
    5) Nutrition subscale to assess the amount of food intake
    6) Friction and shear subscale to measure the patient's ability to assist with movement or be able to move in a way that keeps the skin free of contact with underlying surfaces

Number of Items

6

Time to Administer

20-30 minutes

Required Training

No Training

Age Ranges

Preschool Child

2 - 5

years

Child

6 - 12

years

Adolescent

13 - 17

years

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by Jason Raad, MS and the Rehabilitation Measures Team in 2010;Updated with references for the home health, critical care, and SCI populations by Mike Bruszer, SPT and John Kim SPT in 2011.

Body Part

Upper Extremity
Back
Lower Extremity

ICF Domain

Body Structure

Measurement Domain

General Health

Considerations

Prior research suggest that nurses may be more effective in predicting the development of pressure ulcers than the Braden scale (Salvadalena et al, 1992). Technology-assisted Braden Scale training led to statistically significant improvements in the IRR on 3 of the 6 Braden subscales and yielded better than 80% RN-to-expert agreement on 4 subscales (sensory-perception, activity, mobility, and friction-shear) among new users only (Magnan et al, 2009).

Braden Scale translations:
Chinese: http://med.39.net/zt/20111023/1829695.html
Danish: https://pri.rn.dk/pri/ThyMors/Sider/23b1137c-6ddd-47d9-a22a-883c8f1c3e6b.aspx
French: http://www.cnsa.fr/IMG/pdf/ECHELLES_risque_escarres_.pdf
German: http://www.dekubitus.de/dekubitusprophylaxe-braden-skala.htm
Italian (p15-16): http://www.evidencebasednursing.it/progetti/LGLDD.pdf
Japanese: http://square.umin.ac.jp/sanada/japanese/admin/BradenScale.html
Korean: http://www.kumcansannr.com/sosicji/so0604_3.html
Spanish: http://www.amcg.org.mx/pdfs/socio/seguridad/herramientas/EscaladeBraden.pdf
Portuguese: http://www.ee.usp.br/reeusp/upload/pdf/799.pdf
These translations, and links to them, are subject to the Terms and Conditions of Use of the Rehab Measures Database. RIC is not responsible for and does not endorse the content, products or services of any third-party website, and does not make any representations regarding its quality, content or accuracy. If you would like to contribute a language translation to the RMD, please contact us at rehabmeasures@ric.org.

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Mixed Populations

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Cut-Off Scores

Traumatic Injury: (Baldwin et al, 1998; n = 36; mean age = 31.7 (10.9) years; blunt trauma accounted for 66% of the sample; mean length of stay was 26.5 days)

  • A cut-off score for pressure ulcer risk of 10 yielded a sensitivity of 91% and specificity of 96%

Normative Data

Inpatient care: (VandenBosch et al, 1996)

  • Braden pressure ulcer negative mean score = 18.2 (2.4)
  • Braden pressure ulcer positive mean score = 16.6 (3.0)

Criterion Validity (Predictive/Concurrent)

  • The Sensitivity (ranges from 83% to 100%) and specificity (ranges from 64% to 90%) of the Braden scale suggests the instruments predictive validity (Bergstrom et al, 1987)
  • Nurses were able to predict the development of pressure ulcers in 51.7% of subjects, while they incorrectly predicted the likelihood of developing a pressure ulcer in 41.1% of patients (Bergstrom et al, 1987)
  • Sensitivity, specificity and predictive values for medical and surgical patients were also calculated. (Lindgren et al, 2002)
  • The predictive validity was especially good for medical patients and those with infectious diseases at a cut-off point of ≤ 31. (Lindgren et al, 2002)

Construct Validity

ICU Patients: (Kottner and Dassen, 2010)

ICU 1:

  • Excellent correlation between Braden and VAS (= -0.77)
  • Excellent correlation between Braden and Waterlow (r = -0.71)

ICU 2:

  • Excellent correlation between Braden and VAS (= -0.60)
  • Excellent correlation between Braden and Waterlow (= -0.72)

Responsiveness

Traumatic Injury: (Baldwin et al, 1998)

 

Sensitivity and Specificity for Braden Total Scores

Braden Score

Sensitivity

Specificity

16

9%

71%

15

9%

71%

14

27%

76%

13

45%

81%

12

64%

86%

11

73%

89%

10

91%

96%

9

100%

100%

Older Adults and Geriatric Care

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Standard Error of Measurement (SEM)

Home care: (Kottner et al, 2009; 2007: n = 352 home care clients who took part in the prevalence study were assessed twice, 288 of which completed the Braden Scale; sex = 68% female, 32% male; mean age = 77.8 (11.8) years; 2008:  n = 339 home care clients who took part in the prevalence study were assessed twice, 292 of which completed the Braden Scale; sex = 62.8% female; mean age = 77.4 (13.4) years)

Interrater reliability and agreement coefficients for the Braden Scale and its items:

Year

Items

p

ICC (1,1) (95% CI)

SEM

2007 (n=288)

Sensory Perception

0.87

0.71 (0.65-0.76)

0.34

 

Moisture

0.88

0.81 (0.77-0.85)

0.36

 

Activity

0.87

0.91 (0.89-0.93)

0.26

 

Mobility

0.82

0.86 (0.83-0.89)

0.34

 

Nutrition

0.83

0.78 (0.73-0.82)

0.35

 

Friction & Shear

0.91

0.89 (0.87-0.92)

0.24

 

Total score

0.66

0.90 (0.88-0.92)

1.00

2008 (n=292)

Sensory perception

0.85

0.74 (0.69-0.79)

0.34

 

Moisture

0.85

0.64 (0.57-0.71)

0.40

 

Activity

0.87

0.88 (0.85-0.90)

0.27

 

Mobility

0.81

0.82 (0.78-0.85)

0.38

 

Nutrition

0.84

0.79 (0.75-0.83)

0.29

 

Friction & Shear

0.90

0.83 (0.79-0.86)

0.25

Cut-Off Scores

Home Health: (Kelly et al, 2010; n = 2120 patients aged 60 years and older who were admitted for intermittent skilled home health care and had a documented admission Braden score; mean age = 77.5(8.803) years)

  • For a cut off score of 18, the sensitivity was 73.30% and the specificity was 65.50%
  • The percentage of patients that were correctly classified was 65.61%

Home Health:  (Bergquist et al, 2001; n = 1711 nonhospice patients aged 60 or older who did not have pressure ulcers at the beginning of home healthcare; this was a secondary analysis of data from a retrospective cohort study of risk factors for pressure ulcer development in older adults receiving home health care; mean age for patients with incident pressure ulcers = 78.78 (8.38) years; mean age for patients without pressure ulcers = 76.28 (8.56) years)

  • Cut off score of 19 or less
  • 61% sensitivity
  • 68% specificity

Cut-off Score over Time

Week

Cut-off Score

Sensitivity (%)

Specificity (%)

PVP (%)

PVN (%)

1

19

70

62

9

97

2

20

62

52

8

95

3

18

60

84

17

97

4

20

83

65

25

97

5

18

67

82

17

98

6

19

100

76

11

100

7

17

60

95

50

97

8

18

80

79

27

98

PVN = Predictive Value Negative

PVP = Predictive Value Positive

Home Care: (Ramundo et al, 1995; n = 48 home care patients, 7 of which aquired a pressure ulcer)

  • Cut-off scores for sensitivity:
    • Cut-off score of 11-15: Sensitivity = 14%
    • Cut-off score of 16: Sensitivity = 25%
    • Cut-off score of 17: Sensitivity = 43%
    • Cut-off score above 18: Sensitivity = 100%
  • Cut-off scores for specificity:
    • Cut-off score 11 or below: Specificity = 98%
    • Cut-off score of 12-13: Specificity = 95%
    • Cut-off score of 14-16: Specificity = 80-90%
    • Cut-off score of 17: Specificity = 63%
    • Cut-off score above 18: Specificity = 0-34%%

Skilled Nursing Facility: (Braden and Bergstrom, 1994; n = 102 subjects over the age of 19 free of pressure sore development and admitted within the previous 72 hours to a skilled nursing facility)

  • Cut-off score of 18: Sensitivity = 79% and Specificity = 74%

Critical Care Patients: (Letícia et al, 2011; n = 72 patients admitted to ICUs with a Braden Score of less than 18 and without a pressure ulcer; mean age = 60.9 (16.5) years; mean length of stay = 17.1 (9.0) days)

  • A cut-off score 12 was identified in the first assessment, which showed 85.7% sensitivity and 64.6% specificity
  • A cut-off score 13 was identified in the second assessment, which showed 71.4% sensitivity and 81.5% specificity
  • A cut-off score 13 was identified in the third assessment, which showed 71.4% sensitivity and 83.1% specificity
  • The third assessment showed the best predictive performance in critical care patients

Inpatient care: (VandenBosch et al, 1996, n = 103 subjects hospitalized for a minimum of 7 days and randomly selected from routine hospital admissions; 29 subjects developed pressure ulcers; mean age = 67.0 (13.8) years)

  • Cut-off score was 17, with a sensitivity of 59% and a specificity of 59%

Inpatient Care: (Lindgren et al, 2002; n = 530 patients without pressure sores on admission were assessed over a 12 week period; mean age = 69.25 (14.39) years)

Cut-off Scores, Sensitivity, and Specificity for the Entire Sample

Cut-off Point

Sensitivity

Specificity

≤ 38

77.8%

34.8%

≤ 37

70.4%

46.5%

≤ 36

57.4%

57.6%

≤ 35

50.0%

64.3%

≤ 34

46.3%

69.4%

≤ 33

38.9 %

75.3%

≤ 32

33.3%

80.2%

≤ 31

31.5 %

84.6%

Normative Data

Inpatient care: (VandenBosch et al, 1996)

  • Braden pressure ulcer negative mean score = 18.2 (2.4)
  • Braden pressure ulcer positive mean score = 16.6 (3.0)

Interrater/Intrarater Reliability

ICU Patients: (Kottner and Dassen, 2010; ICU 1:  n = 21 ICU patients and 22 nurse raters; mean age = 69.7 (8.3) years; ICU 2:  = 24 ICU patients and 31 nurse raters; mean age = 67.2 (11.3) years)

 

Interrater Reliability and SEM for Braden Scale:

Scale Item (Score Range)

Strength

ICC (95% CI)

SEM

Braden scale sum score (6–23)

Adequate

0.72 (0.52–0.87)

1.67

1. Sensory perception (1–4)

Adequate

0.64 (0.40–0.81)

0.58

2. Moisture (1–4)

Adequate

0.49 (0.22–0.73)

0.78

3. Activity (1–4)

Poor

0.08 (-0.16 to 0.39)

0.43

4. Mobility (1–4)

Adequate

0.53 (0.27–0.76)

0.46

5. Nutrition (1–4)

Adequate

0.56 (0.31–0.78)

0.49

6. Friction and shear (1–3)

Adequate

0.48 (0.21–0.72)

0.40

Inpatient Care: (Lindgren et al, 2002)

  • Excellent intrarater reliability (ICC = 0.83)

Acute Care Hospital: (Magnan et al, 2009; n = 102 patients in an acute care hospital)

Posttest Comparison of New Users to Regular Users on RN-to-Expert Agreements/Disagreements on Braden Subscale Ratings

Braden Subscale

New Users Count (% within group)

Regular Users (% within group)

X^2

P

Sensory-perception

 

     

Agreements

55 (82.1%)

58 (63.7%)

   

Disagreements

12 (17.9%)

33 (36.3%)

6.38

.012

Moisture

       

Agreements

49 (73.1%)

37 (40.7%)

   

Disagreements

18 (26.9%)

54 (59.3%)

16.41

<.001

Activity

       

Agreements

60 (89.6%)

56 (61.5%)

   

Disagreements

7 (10.4%)

35 (38.5%)

15.52

<.001

Mobility

       

Agreements

54 (80.6%)

57 (62.6%)

   

Disagreements

13 (19.4%)

34 (37.4%)

5.96

.015

Nutrition

       

Agreements

50 (74.6%)

36 (39.6%)

   

Disagreements

17 (25.4%)

55 (60.4%)

19.13

<.001

Friction-shear

       

Agreements

56 (83.6%)

53 (58.2%)

   

Disagreements

11 (16.4%)

38 (41.8%)

11.58

.001

Criterion Validity (Predictive/Concurrent)

  • The Sensitivity (ranges from 83% to 100%) and specificity (ranges from 64% to 90%) of the Braden scale suggests the instruments predictive validity (Bergstrom et al, 1987)
  • Nurses were able to predict the development of pressure ulcers in 51.7% of subjects, while they incorrectly predicted the likelihood of developing a pressure ulcer in 41.1% of patients (Bergstrom et al, 1987)
  • Sensitivity, specificity and predictive values for medical and surgical patients were also calculated. (Lindgren et al, 2002)
  • The predictive validity was especially good for medical patients and those with infectious diseases at a cut-off point of ≤ 31. (Lindgren et al, 2002)

Responsiveness

Home Health: (Kelly et al, 2010)

Sensitivity and Specificity for Braden Total Scores

*Braden Score

Incidence

Sensitivity

Specificity

9

1

3.33

98.63

10

2

6.66

98.68

11

2

6.66

98.67

12

4

13.33

98.77

13

4

16.66

98.81

14

7

23.33

98.89

15

7

23.33

98.86

16

11

36.66

99.00

17

16

53.33

99.19

18

22

73.30

99.40

19

25

83.33

99.50

20

29

96.66

99.82

21

29

96.66

99.60

22

29

96.66

98.25

30

100

0.00

0.00

*Patients whose Braden Scale score was less than or equal to the stated number in column

Spinal Injuries

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Construct Validity

Spinal Cord Injury: (Mortenson & Miller, 2008; A literature review of seven scales that assess the development of pressure ulcers, including the Braden Scale)

  • Poor construct validity in terms of stage of the first pressure ulcer (= 0.03)
  • Adequate concurrent validity with the Norton Scale (= 0.48)
  • Poor concurrent validity with the Waterlow Scale (r = -0.06)

Bibliography

Baldwin, K. M. and Ziegler, S. M. (1998). "Pressure ulcer risk following critical traumatic injury." Adv Wound Care 11(4): 168-173. Find it on PubMed

Bergquist, S. and Frantz, R. (2001). "Braden scale: validity in community-based older adults receiving home health care." Appl Nurs Res 14(1): 36-43. Find it on PubMed

Bergstrom, N.; Braden, B. J.; Laquzza, A.; Holman, V. (1987). "The Braden Scale for predicting pressure sore risk." Nurs Res. 36(4): 205-210.

Kelly, C. (2011). "A new look at the Braden scale for pressure ulcer risk among older adults in home health care." Journal of BSN Honors Research.

Kottner, J. and Dassen, T. (2008). "An interrater reliability study of the Braden scale in two nursing homes." Int J Nurs Stud 45(10): 1501-1511. Find it on PubMed

Kottner, J.; Halfens, R.; Dassen. T. (2009). "An interrater reliability study of the assessment of pressure ulcer risk using the Braden scale and the classification of pressure ulcers in a home care setting." Int J Nurs Stud 46(10): 1307-1312. 

Kottner, J. and Dassen, T. (2010). "Pressure ulcer risk assessment in critical care: interrater reliability and validity studies of the Braden and Waterlow scales and subjective ratings in two intensive care units." Int J Nurs Stud 47(6): 671-677. Find it on PubMed

Leticia, F. S.; de Gouveia Santos, V. L; Campanili, T. C. G. F.; Queiroz, M. (2011)."Predictive validity of the Braden Scale for pressure ulcer risk in critical care patients." Rev. Latino-Am. Enfermagem 19(1): 50-7.

Lindgren, M; Unosson, M.; Kranz, A.; Ek, A. (2002). "A risk assessment scale for the prediction of pressure sore development: reliability and validity." Journal of Advanced Nursing 38(2): 190-199.

Magnan, M.; Maklebust, J. (2009), "Braden Scale risk assessments and pressure ulcer prevention planning: What's the connection?" J Wound Ostomy Continence Nurs. 36(6): 622-634.

Mortenson, W. and Miller, W. (2007). "A review of scales for assessing the risk of developing a pressure ulcer in individuals with SCI." Spinal Cord 46(3): 168-175. Find it on PubMed

Ramundo, J. M. (1995) "Reliability and validity of the Braden Scale in the home care setting." J would Ostomy Continence Nurs. 22(3): 128-134.

VandenBosch, T.; Montoye, C.; Satwicz, M.; Durkee-Leonard, K.; Boylan-Lewis, B. (1996). "Predictive validity of the Braden Scale and nurse perception in identifying pressure ulcer risk." Applied Nursing Research 9(2): 80-86.

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