Pressure ulcer prevalence and incidence and a modification of the braden scale for a rehabilitation unit

Pressure Ulcer Prevalence and Incidence and a Modification of the Braden Scale for a Rehabilitation Unit Richard

M. &hue,

RN, MS, and Diane K. Langemo,

RN, PhD

Purpose: We examined pressure ulcer incidence and prevalence, the cutoff score for risk for skin breakdown, and the contribution of each of the subscale risk factors of the Braden pressure ulcer risk-assessment tool in an inpatient rehabilitation unit. Subjects and Setting: One hundred seventy adult men hospitalized on a rehabilitation unit during 1 calendar year were included in the research. Subject ages ranged from 35 to 99 years (M = 69). Insfrumenfs: Pressure ulcer risk was assessed using the Braden Scale. Methods: A retrospective chart review of a continuous series of 170 adult male patients hospitalized during a l-year period on a 50-bed rehabilitation unit was conducted. Data were documented on a standardized researcher-designed form. Results: A total of 46 pressure ulcers occurred, with the sacrum the most common location (46%), followed closely by the heel-ankle area (44%, n = 20). Most pressure ulcers (57%) were stage II, 24% were stage I, 15% stage Ill, and 4% stage IV. When using a cutoff score of 16, the Braden Scale demonstrated limited usefulness in predicting pressure ulcer development on our inpatient rehabilitation unit. Further calculations were completed, and a cutoff score of 18 or higher was found to provide better predictive value. With use of multiple logistic regression analysis, three of the six risk factors from the Braden Scale were found to significantly contribute to risk for pressure ulcer development in this sample: moisture, nutrition, and friction and shear. Therefore a modified Braden Scale was developed, with a possible range of scores from 3 to 11: the cutoff score was 8, sensitivity was 52%, and specificity 66%. Conclusions: The mean prevalence rate of 12% was comparable, and the incidence rate of 6% for this unit was lower. compared with other skilled care and rehabilitation settings reported in the literature. The proactive, interdisciplinary approach to skin integrity on this unit likely contributed to the lower incidence rate, Risk factors most predictive of pressure ulcer development in this sample were moisture, nutrition, and friction and shear. Predicting risk for skin breakdown with use of a consistent risk-assessment tool is essential for all rehabilitation patients, Assessing risk with the Braden Scale merits further research. (J WOCN 1998;25:36-43)

Mr. Schue is the Unit Manager, Care, Veterans Administration Fargo, North Dakota.

Restorative Hospital,

Dr. Langemo is Professor of Nursing, University of North Dakota, Grand Forks, North

Dakota.

This research was supported Fargo Veterans’ Administration

36

Reprint requests: Diane K. Langemo, PhD. Professor of Nursing, University North Dakota, Sfation, Grand

JO7 J-5754/98/$5.00 21/l/86819

in part by the Hospital.

P. 0. Box 9025, University Forks, ND 58202-9025. + 0

RN, of

ressure ulcers (PUS) are defined by the National Pressure Ulcer Advisory Panel’(NPUAP) as “Localized areas of tissue necrosis that tend to develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time” (p. 25). The Agency for Health Care Policy and Research (AHCPR)2 concurred with the definition and staging schema advocated by the NPUAP (Box 1). Pressure ulcers distress and discourage the patient; provide a route for infection; complicate recovery; greatly increase nursing time, effort, and costs; significantly delay discharge from the hospital; and may contribute to mortality rates in certain patients.3,4 As a result of multiple risk factors, most patients with a spinal cord injury develop a PU at some point after their injury.5 The loss of skin integrity in a patient produces clinically significant consequences for the individual, the institution, and the community. The average estimated cost of treating a PU ranges from $2000 to $25,000.’ The annual financial burden this places on the health care system is estimated to be between $3.5 and $7 billion.6-8 Because of these costs, health care providers are seeking treatment strategies that are both costeffective and clinically effective. One strategy includes the use of assessment tools that warn of potential patient tissue breakdown, allowing for early preventive interventions. Prevention is the preferred management strategy for people judged to be at risk for I?I.Js.*,~,~-~~~~~,~~ In a long-term care facility, an &month study documented a $230,000 savings for the prevention program versus treatment costs.13 Good pre-

P

JWOCN

Volume 25, Number 1

Schue and Langemo

vention programs depend on the identification of risk factors, followed by their elimination or diminution. The ideal prevention program should be cost-efficient, decrease pain and suffering, and document its effectiveness.14 Early identification of patients at risk for PU formation is an imperative component of a prevention program,2 because the preservation of structural (skin) integrity is a key to preventing further ulceration.

Prevalence

and Incidence

Pressure ulcers are a serious problem for patients in any setting, but particularly so for those in the rehabilitation population. Both the incidence (new PU cases appearing during a specified period of time) and the prevalence (a cross-sectional count of the number of PU cases at a specific point in time) appear to be rising.15 The NPUAP’ reported the incidence in chronic care to range from 15% to 25%. Langemo and colleagues17 found a 23% PU prevalence rate and a 28% incidence rate in a skilled care facility. Hammond and associates18 reported a PU incidence ranging from 20% to 60% in patients with spinal cord injury during acute medical stabilization.

Risk Assessment

Instruments

AHCPR Guidelines2 recommend individual evaluation of patient groups judged to be in peril of PU development with use of a validated risk-assessment tool. Two tools were recommended: the Norton Scale or the Braden Scale. The Braden Scale is composed of six mutually exclusive subscales derived from a conceptual schema identifying two major factors responsible for PU development: the amount and duration of pressure, and the tissue’s tolerance of pressure. The six subscales reflect critical determinants of pressure (mobility, activity, and sensory perception) and factors influencing skin’s tolerance for pressure (skin moisture, nutritional status, and friction and shear).19 Each variable is scored on a descending scale of 1 to 4, except for the friction and shear variable, which uses a 3-point scale. The highest attainable score is 23, indicating the least risk for PU formation, whereas lower scores indicate the most risk. A score of 16 or less was calculated as the cutoff score

37

Box. 1 AHCPR’ PU stages Stage

I:

“Nonblancheable ulceration pressure

Stage

II: “Partial

Stage

Ill: ‘Full IV: ‘Full

thickness that

skin-the

should

skin loss involving skin loss involving

may

thickness

damage

of intact

hyperemia

not

heralding

lesion

be confused

with

of skin

stage

ulcers).-

thickness

tissue Stage

erythema (reactive

extend

down

skin loss with

to muscle,

bone,

epidermis damage

to,

but

extensive or supporting

for patient risk, with a sensitivity of 83% to lOO%, and specificity between 64% and 90%.20 Taylo? reported good reliability of the tool when used by registered nurses (RNs) (Y = 0.99), and when used by certified nursing assistants and licensed practical nurses (LPNs) (Y = 0.83 to 0.93). The Braden Scale has been repeatedly evaluated and shows excellent sensitivity and specificity within certain care settings.19,21 According to Braden and Bergstrom, 2* the factors that predispose people to prolonged and intense pressure have been identified as diminished activity, mobility, and sensory perception. These factors are related to tissue tolerance and are influenced by extrinsic and intrinsic factors. Extrinsic factors involve elements that impinge on outer skin layers such as excessive moisture and friction and shear; whereas intrinsic factors influence the integrity and load-absorbing capacity of the skin’s supporting structures.23 Prevention requires skilled nursing assessment of skin integrity and knowledge of risk factors that predispose patients to the development of PUS.~~

PURPOSE The purposes of this study were (1) to determine PU incidence and prevalence in a single rehabilitation unit, (2) to evaluate the cutoff score for risk of developing a PU as put forth in Braden’s original work, (3) to evaluate the Braden Scale subscales and compare the scores obtained from patients in an inpatient rehabilitation facility with those obtained with use of the original scale, and (4) to suggest modifications in the Braden Scale when used with rehabilitation patients, based on the results of the previous experiments.

and/or or necrosis

not

through,

destruction, structures.”

dermis.” of subcutaneous underlying tissue

necrosis

fascia.” or

I

JWOCN January 1998

38 Schue and Langemo

METHODOLOGY

of bony prominences, ongoing assessment, and the use of a trapeze to reduce friction and shear.

Sample Prevalence

One hundred seventy consecutive adult male subjects who were cared for on a 50-bed, acute and chronic care rehabilitation unit of the Veterans Administration hospital during 1 calendar year comprised the study population. The charts of these patients were obtained from the medical records department and reviewed by one of us. Only those patients who were XI-free on admission were included in the incidence study. Institutional Review Board approval for this study was obtained before data were collected.

We calculated prevalence based on a retrospective review of chart skin-integrity forms on all patients on the unit on 2 separate days, 6 months apart (April 1 and October 1). The two rates were averaged to calculate a mean prevalence rate for the unit. The incidence of PU development also was completed by a retrospective chart review of skin-integrity forms on charts of all 170 patients admitted to this unit during the l-year time period (April 1 through March 31).

Methods

Braden Scale Cutoff Score

All subjects were assessed within 24 hours of admission to the unit by the admitting nurse (RN, LPN) according to established agency protocol for the presence of PUS, and this evaluation was documented on the patient’s medical record. When a PU was identified, the NPUAP pressure ulcer grading system was completed. In addition, the Braden Scale for PU risk was completed on all subjects on admission, and weekly thereafter. A data-recording form, which included demographic data, information on the presence of PU risk factors, and the Braden Scale scores, was designed for this study. The tool was reviewed by two PU professionals with expertise in skin care, and pilot tested on five charts, including patients with and without PU. Based on the outcomes of this process, revisions were made. Face validity was established by a thorough literature review and an expert review by two clinicians with expertise in skin care. All unit nursing staff received education on PU assessment, the NPUAP pressure ulcer staging taxonomy, and use of the Braden Scale. This education occurred during formal sessions we provided before implementation of protocols. It was repeated for staff nurses hired during the data-collection period. Staff were thorough in PU risk assessments and interventions, probably owing to expectations and experiences with skin integrity problems in this patient population. In-service education sessions were held regularly to review preventive care, including use of pressure reduction devices, frequent repositioning, padding

The “cutoff score” is the critical point at which patients are deemed to be at significant risk for the development of a PU. The Braden Scale score obtained immediately before the development of a PU was used to compute the mean cutoff score that was best predictive of PU development in this population. This procedure was based on recommendations from Braden and colleagues.*” Sensitivity (true positive rate) and specificity (true negative rate) of the Braden scale were calculated using the Lilienfeld and Lilienfeld formula,25 as recommended by the scale developers (Table 1).

Contribution Risk Factors

of Other Known

Demographic and physiologic information from the data-recording form, the skinintegrity form, and the BradenScale scores were evaluated to determine relationships that justify further research or changes in current practice patterns. The analysis was conducted using descriptive statistics, frequency distributions, and an odds ratio with logistic regression, as well as the relationship of each risk factor to the development of PUS.

RESULTS Sample During the l-year time span of the study, 190 adult males were admitted to this geriatric rehabilitation unit. A total of 170 records were reviewed; 20 records were unavailable because the patients

JWOCN Volume

25, Number

1

had been relocated to another Veterans facility. Subjects’ ages ranged from 35 to 99 years (M = 69.2, SD = 10.9). In comparisons made with Student’s t test, the PLJ-positive (PU+) group was not significantly older than the W-negative (PU) group (M = 71 years, SD = 9.2, versus M = 69 years, SD = 11.5). A total of 46 PUS developed during the study time period. Of these, 24% (n = 11) were stage I, 57% (n = 26) were stage II, 15% (n = 7) were stage III, and 2 or 4% were stage IV. The primary admitting diagnoses for PU- subjects were cerebrovascular accident (stroke) (27%, N = 26), cancer (15%, n = 18), and fractures (13%, M = 16). For the PU+ subjects, cancer (26%, n = 12), peripheral vascular disease (17%, 11= 8), and stroke (13%, n = 6) were the most common admitting diagnoses.

Prevalence

and Incidence

The prevalence of PUS on this unit was calculated from the results of two audits. An audit completed October 1 of the study year documented a PU prevalence rate of 10% (5 of 50 patients), and an April 1 audit revealed a prevalence rate of 13% (6 of 45 patients). Thus the mean prevalence rate for PU on our rehabilitation unit was 12%. Skin-integrity forms on all 170 patient charts were reviewed to ascertain PU development after admission. There were 78% (n = 133) who were PU-, and 22% (n = 37) who were PU+ on admission. After admission, 6% (n = 9) had a PU develop. Pressure ulcers were documented on a total of 46 patients.

Braden Scale Cutoff Score, Sensitivity, and Specificity As recommended by Bergstrom and colleagues, 2othe Braden Scale score obtained immediately before the development of a PU was calculated for the nine nosocomial lesions (range, 11 to 23) identified during the incidence study. PUscale scores ranged from 10 to 23. Thus the cutoff score determined was 16. The Braden Scale had a sensitivity of 46%. Therefore, with use of a cutoff point of 16 to predict PU risk, the scale correctly identified 21 (0.46 x 46 PU+ = 21) patients at risk for PU development, and failed to identify 25 (46 - 21= 25) at risk. The Braden Scale for this sample had a

Schue

Table 1. Braden of the Lilienfeld

Scale sensitivity and specificity and Lilienfeld formula26

PU present No Formulas: Specificity Predictive Predictive

Table 2. Sensitivity (n = 9)

39

with use cutoff

b

C

d

and specificity

% Sensitivity

Above

a Sensitivity a/(a+b) x 100 = %. d/(c+d) x 100 = %. value of a positive test a/(a+c) value of a negative test d/(b+d)

Cutoff score

determination

Below cutoff

Yes

and Langemo

x 100 = %. x 100 = %.

of the Braden

% Specificity

Scale

for predicting

% Predictive value of positive

PUS

% Predictive value of negative

Braden (‘?A) 15 (56)”

30

86

45

77

16 (32)”

36

78

44

80

17 (14)O

59

73

45

83

18 (12)b

72

60

40

85

19 (37f

85

4%

38

89

20(56)b

96

40

37

96

7 (53)”

30

83

40

76

8 (14)”

52

66

36

79

9 (29)b

85

56

42

91

New

(?A)

“Percentage of patients who may have received inadequate preventive measures because they were not identified to be at risk for PUS. A tendency to underpredict percentage. bPercentage of patients tendency to overpredict

who may have received by this percentage.

specificity of 78%. With use of a cutoff point of 16, the scale correctly identified 97 (0.78 x 124 PU- = 97) patients who did not have a PU, but missed 27 patients (124 - 97 = 27) who did experience a PU. The Braden Scale had a predictive value of a positive test (PVPT) of 44%, with PVPT defined as the proportion of subjects who actually had PU develop among those predicted to be at risk (5 16). The scale was correct 44 times, and incorrect 56 times, out of 100. The Braden Scale had a predictive value of a negative test (PVNT) of 80%,. with PVNT defined as the proportion of subjects who did not have PU develop among those predicted to not be at risk (> 16). The scale was correct 80 times, and incorrect 20 times, out of 100. The Braden Scale was better at identify-

unnecessary

preventive

measures.

by this A

40

Schue

JWOCN January 1998

and Langemo

ing those not at risk than those at risk for PU in this sample. With only nine cases to determine the mean cutoff score, sensitivity and specificity results were calculated for all cutoff score values of I5 through 20; using the 16 mean score of the nine PU+ subjects, the scale sensitivity was only 36% and the specificity 78%. There was a resultant increase in sensitivity and decrease in specificity as one advanced up the scale. The cutoff score of 18 had the highest sensitivity (72%) and specificity (60%), with only a 12% tendency to overpredict; therefore, 18 was the recommended cutoff score for this unit (Tables 2 and 3).

Modified

Braden Scale

A modified scale was created based on a logistic regression analysis of the six Braden Scale subscales. The need for this modification occurred because of the relatively poor sensitivity and specificity achieved using the Braden Scale on this inpatient rehabilitation unit (Table 4). Sensory perception, activity, and mobility were eliminated because they were statistically insignificant at the 0.05 level. The remaining risk factors for the modified scale were moisture, nutrition, and friction and shear (with their former numeric subscale weights). Possible modified scale scores ranged from 3 to 11. The process was repeated as previously on the nine PU+ cases identified in the incidence study. PU+ scores ranged from 5 to 10, with the mean cutoff score calculated at 8 (Tables 2 and 3). The modified scale had a sensitivity of 52% versus 46%, specificity 66% versus 78%, PVPT 36% versus 44%, and PVNT 79% versus 80%. When using eight as the cutoff score to predict PU risk, the sensitivity of the modified scale correctly identified 24 (0.52~ 46 PU+ = 24) patients, and failed to identify 22 (46 - 24 = 22) patients, to be at risk. With the same cutoff point of eight, the modified scale specificity correctly identified 82 (0.66~ 124 PU- = 82) patients who would not develop a PU, but missed 42 (124 82 = 42) who would. This indicates that, with use of the modified scale, 14% (versus Braden Scale of 32%) of the subjects could have received inadequate preventive measures because they were not identified as being at risk (Table 2). The ideal instrument would be 100% sensitive and

100% predictive tive tests.*O

for positive

and nega-

Contribution of Other Known Risk Factors Toward the Development of a PU In an attempt to analyze the contribution of each of the six Braden Scale risk factor areas (subscales), and increase predictability, a multiple logistic regression analysis inclusive of all 170 cases was completed. Risk factors with a p > 0.05 were eliminated one at a time. The first factor eliminated was activity (p = 0.7454); second was sensory perception (p = 0.4765); and third was mobility (p = 0.2178). This left moisture (p = 0.0281), nutrition (p = 0.0106), and friction and shear (p = 0.0001) as the most significant predictors for this sample of subjects (Table 4).

Stage of Pressure Ulcers, Site of Development There were 46 PUS. The sacrum was the most common site (n = 21,46%). The heelankle area was a close second with 44% (n = 20), followed by the trochanter (6%, n = 3) and the elbow 4% (n = 2). Of the PUS that developed, 24% were stage I (n = 11); 57% (n y 26) were stage II, making them the most frequently reported; 15% were stage III (n = 7); and stage IV was 4% (n = 2) (Table 5).

DISCUSSION The PU+ and PU- groups shared many similarities. The three most common admitting diagnoses for subjects who had a PU develop were, in descending order, cancer (26%), peripheral vascular disease (17%), and stroke (13%). However, most patients for whom a PU developed had multiple medical diagnoses, which also has been observed in other studies of PU risk.27-29 The mean prevalence (12%) and incidence (6%) rates in this rehabilitation care unit were within previously reported ranges (2.4% to 29.5%) for both prevalence and incidence.zJ7J9,30 The incidence rate was relatively low, which may be attributable to the nursing staff and the interdisciplinary approach on this unit. Distribution of the 46 PUS according to stage, site, and healing time was similar to that of the Meehan** 1994 national PU prevalence survey. The sacral and heel areas

JWOCN Volume 25, Number 1

dominate, comprising 90% of the ulcers in this sample. The association of increased length of stay with a more severe PU (stage II = 43.5 days; stage III = 129 days) demonstrates how this problem can contribute to increased health care costs for affected patients. The Braden cutoff score was determined to be 16 when calculated using the incidence sample (n = 9), as well as the total PU+ sample (n = 46). However, the score at which the instrument was most sensitive (72%) and specific (60%) was 18, with only a 12% tendency to overpredict; thus 18 was the recommended cutoff score for this unit. This study found less sensitivity and specificity than the previously reported sensitivity of 83% to 100% and specificity of 64% to 90% by Braden and Bergstrom.23 Bergstrom and colleagueszO indicated that it is important to set critical cutoff points, giving full consideration to the cost-effectiveness of the preventive treatments and ethical implications. A modified Braden Scale was devised statistically using only subscales with a p < 0.05 on the Braden Scale, and a cutoff score of 8 was determined. At a cutoff score of 8, as compared with the Braden Scale at 18, the sensitivity was 52% versus 46%, and specificity was 66% versus 78%, respectively. The Braden Scale cutoff score of 16 had a tendency to underpredict risk by 32% versus 14% by the new scale, meaning that patients may have received inadequate preventive measures because they were not identified to be at risk for a PU. At a cutoff score of 18, the Braden Scale has a 12% tendency to overpredict versus the modified scale’s 14% tendency to underpredict. Because the Braden Scale score of 16 in this sample of subjects is slightly worse than tossing a coin, our recommendation would be to increase the critical cutoff value to 18 or use the modified scale we have described. Although the modified scale provided a more abbreviated form for our rehabilitation unit, further study is needed. It was surprising that the risk factors of mobility, activity, and sensory perception were not predictive of PU development in this sample. We recommend caution because retrospective data have inherent problems, such as the potential for missing data, poor interrater

Schue and Langemo

Table 3. Braden Scale cutoff scores determination Liiienfeld and Lilienfeld formulaz6 PU present

with use of the

< = 16 (Cutoff)

> 16 (Cutoff)

a (21)

b (25) d (97)

Yes No

c

(27)

Formulas: Sensitivity a/(a+b) x 100 = % 21/(21+25)x100=45.6%. Specificity d/(c+d) x 100 = % 97/(27+97) x 100 = 78.2%. Predictive value of a positive test a/(a+c) x 100 = % 21/(21+27)x 100=43.7%. Predictive value of a negative test d/(b+d) x 100 = % 97/(25+97)x 100 = 795%.

Table 4. Unweighted factors Risk factors

Coefficient

SE

0.28903

0.40594

0.71

0.4765

0.64253

0.29265

2.20

0.0281*

0.11634

0.35823

0.32

0.7454

-0.44543

0.36142

-1.23

0.2178

-0.62804

0.24620

-2.55

0.0107*

- 1.53424

0.37360

-4.11

0.0001*

Sensory perception Moisture Activity Mobility Nutrition Friction and shear SE, Standard

logistic regression of the six Braden Scale risk Coefficient/SE

P

error. *p < 0.05.

Table 5. Stage of PU related to site of development Stage

Sacral

Heel

Elbow

Hip

Stage total

%

I

6

4

0

1

11

24

II III IV Site total

11

12

2

1

26

57

3

3

7

15

1

0 0

1

1

0

2

4

21

20

2

3

46

100

% of site

46

44

4

6

reliability, and differences in PU severity staging. Another limitation is that only nine patients on this unit had a PU develop during the course of the study, thereby confining generalizations.

RECOMMENDATIONS Education is the basis of any comprehensive prevention program. Preventive measures must include the patient, family, and the interdisciplinary team responsible for the care.2 All team members must remain apprised regarding risk factors,

41

JWOCN January 1998

42 Schue and Langemo

risk assessments, prevention and early intervention measures, and treatments. Because of the critical PU time-pressure relationship, it is essential at the time of admission, and when any significant change occurs in the patient’s condition, that assessments be done regularly to identify those at risk and implement preventive actions. Using a risk-assessment tool is also important.* We recommend that health care agencies who care for patients at risk for PUS obtain the 1992 and 1995 AHCPR Pressure Ulcer Guidelines,*r31 and incorporate the recommendations from these resources into the agency’s PU protocols. The ideal PU risk-prediction instrument would adapt readily to various clinical settings; however, this is as yet unavailable because of patients’ multiple underlying diseases, medications, and treatment variables. Norton3* cautions, “No scale, however sophisticated, canbe more than an indicator of risk.” The nursing profession needs to remain actively involved in the development and refinement of PI-J risk-assessment tools that are population specific. Further research should be directed toward replication of this study to include a larger sample, as well as other inpatient and outpatient rehabilitation settings. In addition, a large, longitudinal study would assist in understanding prospectively the evolution of a PU and its accompanying risk factors. A study focusing on the costs and cost-effectiveness related to risk assessment and prevention versus costs for care of patients with different stages of PUS would also be beneficial. REFERENCES 1. National Pressure Ulcer Advisory Panel. Pressure ulcer prevalence, cost and risk assessment: Consensus Development Conference statement.

Decubitus

1989;2:24-8.

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injuries.

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Wound

Care

6. Maklebust J, Bruckhorst L, Cracchiolo-Caraway A, Ducharme MA, Dundon R, Panfill R, et al. Pressure ulcer incidence in high risk patients managed Decubitus

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Mobility of elderly patients in bed: measurement and association with patient condition. J Am Geriatr Sot 1986;34:633-6. 11. Hale J, Smith S. Pressure reduction versus pressure reduction overlays: analysis. J ET Ther 1990;17:241-3. 12. Lishinsky ES. A philosophy sores in hospice patients.

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16. Regan MB, Byers PH, Mayrovitz HN. Efficacy of a comprehensive prevention program in an extended care facility. Adv Wound Care 1995;8:49-55. 17. Langemo DK, Olson Burd C, Cathcart-Silberberg pressure extended

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B, Hunter S, Hanson T. The incidence

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19. Bergstrom N, Demuth PJ, Braden BJ. A clinical trial of the Braden Scale for predicting pressure sore risk. Nurs Clin North Am 1987;22:417-28. 20. Bergstrom N, Braden 8, Laguzza A, Holman V. The Braden Scale for predicting pressure sore risk.

2. Agency for Health Care Policy and Research. Pressure ulcers in adults: prediction and preven-

Nursing Res 1987;36:205-10. 21. Taylor KJ. Assessment

tion. Rockville (MD): USHHS; 1992 clinical practice guideline No. 3, AHCPR Pub. No. 92-0047.

tion of patients at risk for the development of pressure sores. J ET Ther 1988;15:201-5. 22. Braden B, Bergstrom N. A conceptual schema

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pressure ulcer treatment guidelines. Columbus (MD): Agency for Health Care Policy and Research; 1994 Center for Health Policy Studies No. 282-91-0070. 5. Niazi ZBM, Salzberg CA, Byrne DW, Viehbeck M. Recurrence

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25. Lilienfeld AM, Lilienfeld DE. Foundations of epidemiology. 2nd ed. New York: Oxford Universih/ Press; 1980. 26. Hunter S, Cathcart-Silberberg T, Langemo DK, Olson B, Hanson D, Burd C, et al. Pressure ulcer prevalence and incidence in a rehabilitation hospital. J Rehabil Nursing 1992; 17:239-42. 27. Langemo DK, Olson B, Hunter S, Hanson D, Burd C, Cathcart-Silberberg T. Incidence and prediction of pressure ulcers in five patient care settings. Decubitus 1991;4:25-6. 28. Meehan M. National pressure ulcer prevalence survey. Adv Wound Care 1994;7:27-38.

43

29. Gerson LW. The incidence of pressure sores in active treatment hospitals. Int J Nurs Stud 1975;12:201-4. 30. Shannon ML, Skorga P. Pressure ulcer prevalence in two general hospitals. Decubitus 1989;2:38-43. 31. Agency for Health Care Policy and Research. Treatment of pressure ulcers. Rockville (MD): US DHHS; 1995 clinical guideline No. 15, AHCPR Pub. No. 95-0652. 32. Norton D. Calculating the risk: reflections on the Norton Scale (abstract). Decubitus 1989;2:24.

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