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Background: Critically ill patients are at high risk for pressure ulcers., Objectives: To determine the contributions of the Braden subscales in predicting pressure ulcers in critically ill patients and to investigate how often the Braden scale should be completed to assess the risk for pressure ulcers in critically ill patients., Method: The Braden scale was used to assess repeatedly 136 adult patients without pressure ulcers in a medical intensive care unit, a surgical intensive care unit, and a noninvasive respiratory care unit, and the patients' skin was inspected routinely for pressure ulcers., Results: A total of 36 pressure ulcers, most commonly on the sacrum or coccyx and the heels (15 stage 1, 20 stage 2, 1 stage 3), developed in 17 patients (12%). In 14 (82%) of the 17, the ulcers developed within 72 hours of admission to the intensive care unit. The risk for pressure ulcers increased as the mean sensory perception (P = .01) and the mean total Braden (P = .046) scores decreased. The mean sensory perception scores obtained at 12 and 36 hours after admission also had a significant relationship to the risk for pressure ulcers (P = .03)., Conclusions: Patients in intensive care units have an increased risk for pressure ulcers. Although waiting until 12 hours after a patient's admission to the intensive care unit to obtain the initial Braden rating may be reasonable (with the second rating obtained 36 hours after admission), additional research is needed before this practice can be recommended.

Background: There have been no studies that have tested the Braden Scale for predictive validity and established cutoff points for assessing risk specific to different settings., Objectives: To evaluate the predictive validity of the Braden Scale in a variety of settings (tertiary care hospitals, Veterans Administration Medical Centers [VAMCs], and skilled nursing facilities [SNFs]). To determine the critical cutoff point for classifying risk in these settings and whether this cutoff point differs between settings. To determine the optimal timing for assessing risk across settings., Method: Randomly selected subjects (N= 843) older than 19 years of age from a variety of care settings who did not have pressure ulcers on admission were included. Subjects were 63% men, 79% Caucasian, and had a mean age of 63 (+/-16) years. Subjects were assessed for pressure ulcers using the Braden Scale every 48 to 72 hours for 1 to 4 weeks. The Braden Scale score and skin assessment were independently rated, and the data collectors were blind to the findings of the other measures., Results: One hundred eight of 843 (12.8%) subjects developed pressure ulcers. The incidence was 8.5%, 7.4%, and 23.9% in tertiary care hospitals, VAMCs, and SNFs, respectively. Subjects who developed pressure ulcers were older and more likely to be female than those who did not develop ulcers. Braden Scale scores were significantly (p = .0001) lower in those who developed ulcers than in those who did not develop ulcers. Overall, the critical cutoff score for predicting risk was 18. Risk assessment on admission is highly predictive of pressure ulcer development in all settings but not as predictive as the assessment completed 48 to 72 hours after admission., Conclusions: Risk assessment on admission is important for timely planning of preventive strategies. Ongoing assessment in SNFs and VAMCs improves prediction and permits fine-tuning of the risk-based prevention protocols. In tertiary care the most accurate prediction occurs at 48 to 72 hours after admission and at this time the care plan can be refined.

Objective: To determine the incidence of pressure ulcers in varied populations, and whether demographic characteristics (age, gender, race) and primary diagnosis are factors in pressure ulcer development when the level of risk for developing ulcers is considered. To determine if there is a difference in the type of preventive services prescribed for persons who do or do not develop pressure ulcers when risk is controlled and whether differences can be related to demographic characteristics., Design: Cohort study., Setting: Two skilled nursing homes, two university operated tertiary care hospitals, and two Veteran's Administration Medical Centers (VAMCs) in Omaha, NE, Durham, NC, and Chicago, IL., Patients: A total of 843 randomly selected patients more than 19 years of age who did not have pressure ulcers on admission to their place of care. Subjects were 63% male, 79% white, and had a mean age of 63 (+/- 16) years., Measures: A head-to-toe skin assessment for pressure ulcers recording site and stage of ulcers, scores for the Braden Scale for Predicting Pressure Sore Risk, demographic characteristics (age, sex, race), and primary diagnosis and preventive interventions (turning or repositioning orders and pressure reduction surface) were documented on the patient record. Observations were made every 48 to 72 hours for a minimum of 1 to a maximum of 4 weeks., Main Outcome Measures: Presence/absence and stage of pressure ulcers., Main Results: One hundred eight of 843 (12.8%) subjects developed pressure ulcers. The incidence was 8.5%, 7.4%, and 23.9% in tertiary care, VAMCs, and nursing homes, respectively. Logistic regression demonstrated that lower Braden Scale scores, older age and white race predicted pressure ulcers; gender was not predictive. Primary diagnoses were not significant predictors of pressure ulcer risk when the Braden Scale score was entered into the regression. Prescription of turning was predicted by Braden Scale scores and by white race, whereas prescription of pressure reduction was predicted by Braden Scale scores, white race, and female sex., Conclusions: Risk assessment, rather than diagnoses or demographic characteristics, is recommended as the basis for prescriptive decisions. Risk assessment should cue health care providers to make more judicious use of turning and support surfaces to prevent pressure ulcers. Persons who are at risk for pressure ulcers should have turning and pressure reduction surfaces consistently prescribed and implemented. The costs and goals of preventive prescription for those not at risk for pressure ulcers should be considered.

Because critical care nurses recognize that many of their patients are at risk for pressure ulcer development, they provide them with support surfaces that can reduce this risk. Few reported studies, however, are available to help these nurses choose these surfaces wisely. This project was a new-product evaluation that compared the clinical effectiveness of three types of support surfaces: two dynamic mattress replacement surfaces and a static foam mattress replacement. Members of a convenience sample of 110 patients admitted to a surgical intensive care unit each used one of the three support surfaces. When each patient was placed on one of the three surfaces, the evaluators rated likelihood of pressure ulcer development (Braden Scale score) and assessed the skin for pressure ulcers. The evaluators repeated the Braden Scale score weekly and the skin assessment three times each week. Nine patients (8%), three patients on each support surface, acquired pressure ulcers. The log-rank test did not find a statistically significant difference between the three types of support surfaces with respect to the risk of pressure ulcer development. Stepwise Cox proportional hazards regression revealed a statistically significant relationship between the risk of developing a pressure ulcer, the averaged total Braden Scale score, and the averaged score for the sensory perception subscale of the Braden Scale. Although these three surfaces were comparable in effectiveness, they were not comparable in cost. Both dynamic mattress replacement surfaces cost approximately $2000 each, whereas the cost of the static foam mattress replacement was only $240 each. The results of this product evaluation should encourage other nurses to evaluate patient care products carefully before making recommendations.

1. Skin that is damp or wet is more permeable to irritating substances and more readily colonized by microorganisms. Less friction is required to abrade or blister skin when it is damp. 2. The goal of nurses who care for patients at risk for skin breakdown secondary to moisture and associated irritants is to keep the skin dry and free of irritants. 3. Although there are many products that claim to protect the skin from the injurious effects of moisture, the research supporting these claims is limited. Nurses, therefore, must be inquisitive and vigilant when selecting products.

Nurses caring for elderly patients often need to select support surfaces that reduce the likelihood of pressure ulcers, but there is little information about the effectiveness of different support surfaces. This randomized trial compared two support surfaces and investigated patient attributes related to the risk of developing a pressure ulcer. Eighty-four elderly patients were nursed on a convoluted or solid foam overlay and assessed three times a week for pressure ulcers. Stepwise Cox proportional hazards regression revealed a statistically significant relationship between the risk of developing a pressure ulcer and the variables mobility and type of support surface.

By highlighting theories of knowledge utilization, we consider some of the factors and issues in planning research utilization projects. By our use of a research utilization model in developing a research-based pressure ulcer prevention program, we help to bridge the gap between research and practice.

In this prospective study examination was made of whether (a) time on the operating table, (b) proportion of intraoperative diastolic hypotensive episodes, (c) age, (d) preoperative serum albumin, (e) preoperative total protein levels, and (f) preoperative Braden scores could identify those patients who do and do not develop pressure sores during elective surgery. The stratified sample consisted of 125 adult patients. Fifteen patients (12%) developed a total of 23 pressure sores. A discriminant function using time on the operating table, extracorporeal circulation, and age emerged as the best predictor correctly classifying 12 of 15 patients who developed pressure sores and 83 of 110 patients who remained pressure sore free.