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pressure injuries do so because of issues related to malnutrition.10 Therefore, patients at risk for both
malnutrition and pressure injury
development need to be identied for
early
nutrition
assessment
and
intervention.
BACKGROUND
Pressure Injury Screening Tools
Multiple tools are available to identify
the risk for development of a pressure
injury. The Norton Scale, the Braden
scale, Waterlow Scale, and the BradenQ scale are a few of these, with the
Braden scale being the most widely
used in US hospitals. The Braden scale
for Predicting Pressure Sore Risk11 is an
assessment tool that was developed by
Barbara Braden in 1987 and tested by
several clinicians as a part of a research
project. Since that time, this pressure
injury prediction tool has been integrated into nursing assessment of
pressure injury risk in various health
care settings in the United States and
around the world. Compared with
similar pressure injury risk assessment
scales such as the Norton or Waterlow
scales, the Braden scale has been found
to have the most ideal combination of
sensitivity (57.1%), specicity (67.5%),
and risk estimation (odds ratio4.08,
95% CI2.56-6.48).12 The Braden scale
assesses patients by using six categories, each found to play a role in
pressure injury formation: sensory
perception, moisture, activity, mobility,
nutrition, and friction and shear. Each
category is scored from 1 to 4 (or 1 to 3
for friction/shear), to yield a maximum
cumulative score of 23. In the acute
care setting, patients are often assessed
by nursing staff on admission and
again every set number of hours
beyond that (for example, once every
12-hour nursing shift or once per day).
Based on a patients total Braden score,
patients are determined to be at mild
(score of 15-18), moderate (13-14),
PRACTICE APPLICATIONS
high (10-12), or severe (9) risk for
developing a pressure injury.
Nutrition is one of the six subscales
of the overall Braden scale and is
intended to gauge a patients usual
food intake pattern by considering how
much of their meals they typically
consume, their average protein intake,
whether they are consuming any
nutritional supplements, and whether
they are receiving nutrition via enteral
or parenteral nutrition.11 Neither the
total Braden scale score nor the nutrition subscale score have been independently validated for use as a tool to
predict risk of malnutrition.
Hospital policies and procedures
often dictate certain interventions
by multidisciplinary care teams to
appropriately monitor, prevent, and
treat pressure injuries based on the
degree of risk predicted by the total
Braden scale score. Because malnutrition has been proven to increase pressure injury risk and delay healing,7-10,13
one of these interventions is often a
referral to a registered dietitian nutritionist (RDN) for patients with a low
total Braden score or nutrition subscale
score. Of note, an informal survey of
acute care hospitals in the United
States indicated that the cutoff score
for the Braden scale scores that trigger
a nutrition referral are inconsistent.
Some hospitals use the nutrition subscale score in addition to the overall
Braden scale score for risk stratication
and determination of whether to refer
a patient to the RDN13 (M. Hershey,
personal communication at statewide
nutrition conference of the Virginia
Academy of Nutrition and Dietetics,
April 12, 2016).
Regardless of the cutoff value used to
initiate an RDN referral for further
assessment and nutrition intervention,
the total Braden scale score has not
been validated to identify patients for
whom specialized nutrition assessment and intervention by an RDN is
necessary or appropriate. Furthermore,
since its development in 1987, of the
numerous studies that have been conducted to assess the validity of the
Braden scale and its subscales for predicting pressure injury risk, many have
concluded that the Braden scale is
highly overpredictive of actual pressure
injury development.14-16 In other
words, not all patients who are
predicted to develop a pressure
injury actually develop one. This
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Table 1. Categorization of
unintentional weight loss with
corresponding points assigned
using the validated Malnutrition
Screening Tool
If yes, how much weight
(kilograms) have you lost?
1-5
6-10
11-15
>15
Unsure
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PRACTICE APPLICATIONS
Table 2. Comparison of Braden Scale score with Malnutrition Screening Tool
(MST) scorea
MST Score
Braden risk category
Mild
38
Moderate
20
High
11
12
71
18
Very high
Total
11
73
27
19
15
121
The total score on the Braden Scale places the patient in a risk category of either none, mild, moderate, high, or very
high. This table indicates the corresponding score on the MST for each of the patients in each of those Braden risk
categories, with the total number of patients in each group indicated in the table.
FINDINGS
Comparison of MST and Braden
Scale Scores
The average age of the 121 patients was
61.9 years, with 40% of patients from
ICUs and 60% from acute care units. The
average initial Braden scale score was
14.2 for ICU patients and 15.4 for patients on acute care units.
Of the 121 patients, 89 (73.5%) had an
MST of either 0 or 1, which would indicate that the patients were not at risk for
malnutrition. Of those patients, 16 (18%)
were in the high or very high risk Braden
scale category, with the other 82% of
patients being in the mild to moderate
risk Braden scale category (Table 2). Of
the 121 patients, 32 patients (26.5%)
scored 2 points on the MST, indicating
risk for or presence of malnutrition. Of
these, only 5 (16%) had a Braden scale
score in the high risk or very high risk
category. This would suggest little correlation between the malnutrition risk
Table 3. Comparison of nutrition subscale scores of the Braden scale with the
Malnutrition Screening Tool (MST) scorea
MST Score
Nutrition subscores
Total
32
11
10
63
38
53
71
18
15
121
a
The score on the nutrition subscale is compared to the MST score. This table indicates the corresponding score on the
MST for each of the patients with each of the nutrition subscale scores, with the total number of patients in each group
indicated in the table.
score and the pressure injury development risk score. Because of the variance
in the way scores are distributed within
risk categories between the MST and the
Braden scale, the data were not distributed in a way that would allow for data
analysis to determine whether this was
a statistically signicant difference.
Because of the nature of the scale itself
and current research on the utility and
reliability of the Braden scale, for
assessment coordinators to change the
score categories would have been
inconsistent and undesirable. A similar
pattern was seen when the nutrition
subscale scores were compared against
the MST score (Table 3). Interestingly, no
patients received a 4 (excellent) on the
nutrition subscale score, and only 5 of
121 received a 1 (very poor).
Although the Braden scale score is not
used as a nutrition screening referral in
this hospital, and only 26.5% of the patients scored 2 or more points on the
MST, 65% of patients who scored less
than 18 on the Braden scale were seen
by an RDN (Table 4). Patients in the very
high risk category were seen 100% of the
time (n2), and patients in the high risk
category were seen 79% of the time
(n19). Likewise, 100% of patients with
a nutrition subscale score of 1 (n5) and
73% of those with a nutrition subscale
score of 2 (n62) were seen by the RDN.
This conrms that other measures are in
place to trigger RDN involvement in the
patients care, and the Braden scale
score or the nutrition subscale score are
not necessary triggers for RDN referral.
Results of the survey to assess
nursing training on how to score the
nutrition subscale of the Braden, their
scoring condence, and knowledge of
scoring criteria conrmed the potential
Seen by RDN
Braden risk
category
%
Yes No Seen
Mild
43 30
60%
Moderate
19
70%
High
15
79%
Very high
0 100%
79 42
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65%
Number
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Table 5. Percent of nurses
answering with the desired response
on the nursing survey
Question 1: Trained on scoring 23%
the nutrition subscale of the
Braden scale?
Question 2: Condent in scoring 50%
the nutrition subscale of the
Braden scale?
11%
Question 3: Scoring nutrition
subscale of the Braden scale
using correct assessment?
Question 4: Can correctly
describe what the various
subscores indicate?
59%
64%
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see whether the results are generalizable to a larger population across multiple facilities.
Effective use of an overall Braden
scale score or the nutrition subscale
score as a nutrition screening trigger
for a referral to the RDN for subsequent
assessment and intervention depends
on its accuracy and interrater reliability. Numerous studies note the
inconsistency of the scales scores and
overpredictability for forecasting risk
of developing a pressure injury. The
literature suggests that the nutrition
subscale score is the most inaccurate of
all the scores, likely because of the
difference in how it is assessed
compared with the other subscales.
This assessment conrmed those outcomes, because most of the nursing
staff surveyed are incorrectly assessing
patients nutrition risk using the Braden scale. Inaccurate scoring could
produce an unnecessarily high number
of RDN referrals, leading to additional,
unwarranted work for the RDN that
could be directed toward patients
at higher nutritional risk. Because
malnourished patients are at greater
risk of developing pressure injuries, for
purposes of targeting nutrition intervention, identifying patients at risk for
malnutrition, not necessarily those at
risk for developing pressure injuries, is
important. The use of a validated
nutrition screening tool, such as the
MST,22 can help to identify these patients. Ongoing communication with
the health care team and adequate
documentation of key assessment factors such as percent meal intake and
intake of oral, enteral, and parenteral
nutrition during a patients hospital
stay can help the RDN identify which
patients are in need of specialized
nutrition interventions to prevent
all malnutrition-associated adverse
events, including pressure injuries.
References
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DISCLOSURES
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
No potential conict of interest was reported by the authors.
FUNDING/SUPPORT
No authors have any conicts of interest or funding sources to disclose.
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