Braden Assessment for Pressure Ulcer Prevention
Direct Recommendation
Clinicians should perform Braden Scale risk assessment to identify patients at risk for pressure ulcers, but recognize that this tool has limited diagnostic accuracy and should not replace clinical judgment in implementing preventive interventions. 1
Understanding the Braden Scale's Role
The Braden Scale serves as a structured risk assessment tool, but its performance characteristics reveal important limitations:
Moderate-quality evidence demonstrates the Braden Scale has low sensitivity and specificity for identifying patients who will develop pressure ulcers. 1 This means it will miss some at-risk patients while flagging many who won't develop ulcers.
The diagnostic accuracy of the Braden Scale does not differ substantially from other risk assessment tools (Norton, Waterlow, Cubbin and Jackson scales) or even from experienced nurses' clinical judgment alone. 1
In trauma and burn populations specifically, the Braden Scale shows particularly poor discriminatory ability, with a positive likelihood ratio that never reaches clinically useful thresholds. 2 At the traditional cutoff of ≤18, sensitivity is 100% but specificity is only 6%, resulting in excessive false positives.
When and How to Use the Braden Scale
The American College of Physicians recommends performing risk assessment (weak recommendation, low-quality evidence), with the caveat that tools may be especially useful for clinicians without expert gestalt. 1
Practical Implementation Strategy:
Perform Braden Scale assessment on admission and reassess regularly based on clinical condition changes, particularly in geriatric patients and those with neurological conditions who have multiple risk factors. 3, 4
Focus on individual subscale scores rather than relying solely on total score. 5 Research shows 19% of patients with "not-at-risk" total scores (>18) still had low subscale scores indicating need for targeted interventions.
Pay particular attention to sensory perception (highest factor loading), followed by mobility and moisture subscales, as these are the most predictive components. 6
Modified Risk Classification:
- High risk: Braden score <11 (predicted ulcer incidence >10%) 7
- Moderate risk: Braden score 12-16 (predicted ulcer incidence 1-10%) 7
- Mild risk: Braden score >17 (predicted ulcer incidence <1%) 7
This modified 3-group classification shows significantly different observed pressure ulcer incidence between categories, unlike the traditional 5-group classification. 7
Critical Preventive Interventions (More Important Than the Assessment Itself)
Regardless of Braden score, implement these evidence-based interventions for at-risk patients:
Support Surfaces (Strongest Evidence):
Use advanced static mattresses or advanced static overlays for all patients at increased risk (strong recommendation, moderate-quality evidence). 1 No specific brand has proven superiority.
Avoid alternating-air mattresses or overlays as they are not superior to advanced static surfaces and are more expensive (weak recommendation, moderate-quality evidence). 1
Repositioning Protocol:
Implement systematic repositioning every 2-4 hours for all at-risk patients, using the 30-degree tilt position rather than 90-degree lateral rotation. 3 The 30-degree position reduces pressure on bony prominences with a relative risk of 0.62.
When using advanced pressure-reducing mattresses, repositioning intervals can be extended to 4 hours without increased ulcer incidence. 3
Skin Care and Nutrition:
Conduct thorough visual and tactile skin checks of all at-risk areas (sacrum, heels, ischium, occiput) at least once daily. 3
Provide protein supplementation for patients with nutritional deficiencies, as malnutrition significantly impairs wound healing. 3, 4
Keep skin clean and dry, addressing incontinence promptly as it increases skin maceration and ulcer risk. 3
Common Pitfalls to Avoid
Do not rely exclusively on total Braden score to trigger interventions. 5 Patients with scores >18 may still need targeted interventions based on individual subscale deficits.
Do not assume the Braden Scale accurately predicts risk in trauma/burn populations. 2 These patients require heightened clinical vigilance regardless of score.
Do not delay preventive interventions while waiting for formal risk assessment. 1 Clinical judgment identifying obvious risk factors (immobility, incontinence, malnutrition) should prompt immediate action.
Do not use the Braden Scale as a substitute for implementing multicomponent prevention programs. 1 Successful prevention requires standardized protocols, multidisciplinary teams, designated "skin champions," ongoing staff education, and sustained audit and feedback.
Special Population Considerations
Geriatric Patients:
- Older age, lower body weight, and cognitive impairment are independent risk factors that compound pressure ulcer risk. 1, 4 These patients require intensive preventive measures even with borderline Braden scores.
Neurological Conditions:
Patients with spinal cord injuries and impaired sensory perception represent the highest-risk category based on factor loading analysis. 6 Begin mobilization as soon as the spine is stabilized, starting with passive range-of-motion exercises for at least 20 minutes per zone. 3
Cognitive impairment limits ability to communicate discomfort or reposition independently, necessitating more frequent staff-initiated position changes. 4
Long-Term Care Setting Limitations
Meta-analysis of 41,489 long-term care residents demonstrates the Braden Scale has only moderate predictive validity (AUC 0.77) and particularly low specificity (0.42) in this setting. 8 Development of new risk assessment scales specifically for long-term care populations is warranted.