Tracie Jones, BSN, RN, CWOCN, WCC, COS-C Todd Springfield, BSN, RN, CWOCN

Transcription

1 Tracie Jones, BSN, RN, CWOCN, WCC, COS-C Todd Springfield, BSN, RN, CWOCN 1 Identify the six stages of pressure ulcers using the revised NPUAP staging g system. Demonstrate how to accurately complete the pressure ulcer data elements on the OASIS-C using the guidance provided by CMS. Identify how to implement the Braden Risk assessment to ensure data accuracy and select evidence-based d interventions i to mitigate the patient s risk for pressure ulcer development based upon risk scores. 2 1

2 A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a boney prominence, as a result of, pressure, or pressure in combination with shear and/or friction. 3,10 3 Location, Location, Location trochanter Lateral Position Prone Position Supine Position Sitting Position 4 2

3 Abnormal redness of the skin due to capillary congestion Transient increase in organ blood flow that occurs following a brief period of ischemia Non-blanchable Erythema Reactive Hyperemia (Transient Erythema) 5 Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. 3,10 Used with permission of the National Pressure Ulcer Advisory Panel,

4 Intact skin with non-blanchable erythema of a localized area usually over a boney prominence. 3,10 Used with permission of the National Pressure Ulcer Advisory Panel, Partial thickness loss of dermis presenting as a shallow open ulcer with red/pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. 3,10 Used with permission of the National Pressure Ulcer Advisory Panel,

5 Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. 3,10 Used with permission of the National Pressure Ulcer Advisory Panel, Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. 3,10 Used with permission of the National Pressure Ulcer Advisory Panel,

6 Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar. The true wound depth, and stage, can not be determined until enough slough and/or eschar is removed to expose the base of the wound. 3,10 Used with permission of the National Pressure Ulcer Advisory Panel, Epidermis i Basement Membrane Dermis Sebaceous Gland Hair bulb and shaft Eccrine Sweat Gland Hypodermis Muscle Fibers Sensory Nerve Fibers 12 6

7 Tissue destruction extends through the epidermis into but not through the dermis. Reprinted with permission from AAWC (2007). Educational 13 Images CD. Tissue destruction extends through the epidermis, dermis, into and/or through the subcutaneous tissue. 14 7

8 Regeneration of the epidermis across a wound surface Rete ridges important in epithelialization Lateral migration in partial thickness and full thickness wounds; Vertical migration in partial thickness wounds (Epithelial islets) 4 Partial thickness wound healing Restores the functional integrity of the skin No scar formation! 15 Full thickness wounds fail to regenerate bone, muscle, tendon, or adipose tissue. Without restratification of the layers, the dead space fills with granulation/scar tissue. This is why a Stage III/IV never heals. Does not restore the functional integrity of the skin. 16 8

9 Granulation Neoangiogenesis Matrix deposition Collagen Synthesis Scar Tissue Contraction Fibroblast exert tractional force on ECM Epithelialization Lateral migration Scarred tissue up to 80% as strong as intact dermis after 2 years! Reprinted with permission from AAWC (2007). Educational Images CD. 17 Identifies whether the agency clinician assessed the patient s risk of developing pressure ulcers. 7,8 18 9

10 Identifies if the patient is at risk for developing pressure ulcers. 18 or less on the Braden Risk Assessment is significant for at risk individuals. 7,8 19 Identifies the presence or absence of Unstageable or unhealed stage II or higher pressure ulcers Stage II pressure ulcers heal through the process of regeneration of the epidermis across the wound surface known as epithelialization. Stage II and IV pressure ulcers heal through contraction, granulation, and epithelialization. Never fully healed but considered closed when they are fully granulated and epithelial tissue covers the wound surface. 7,

11 Identifies: The oldest stage II pressures ulcer present at the time of discharge that is not fully epithelialized The length of time this ulcer remained unhealed while the patient received care from the home health agency Patients who develop stage II pressure ulcers while under the care of the agency 7,8 21 Item refers only to nonepithelialized Stage II pressure ulcers. OPEN Select NA if the patient has no Stage II pressure ulcer at the time of discharge or all have been fully epithelialized CLOSED Select 1 if the oldest open Stage II pressure ulcer was already present when the SOC/ROC was complete Select 2 if the oldest open Stage II pressure ulcer was identified since the most recent SOC/ROC Capture date if occurred on our watch 7,

12 Identifies the number of Stage II or higer pressure ulcers at each stage present at the time of assessment. Stage I pressure ulcers are not captured in this item. Column 1 answered at SOC/ROC/FU & DC Column 2 answered at FU & DC 7,8 23 7,

13 Open Stage II pressure ulcers are captured; closed Stage II pressure ulcers are not captured. Capture open and closed Stage III and IV pressure ulcers at the time of the assessment. Report at worst stage! Remember that Stage III/IV are never fully healed. Look for scarring and other signs of past pressure ulcers when answering this item. Scar Tissue 7,8 25 Captures the measurement of the wound with the largest surface area Measure every existing open Stage III, IV, or Unstageable (due to necrosis) pressure ulcer Identify the wound with the largest surface area, then include the measurements in the OASIS: Length- head to toe measurement- longest 12-6 Width- longest 3-9 Depth- measure deepest part of wound 7,

14 If all Stage III or IV pressure ulcers are a) closed (completely reepithelialized); or b) Unstageable due to the presence of a nonremovable dressing report 00.0 in M1310, M1312, M1314. If the wound is unstageable due to the presence of necrosis, then report the actual length in M1310, width in M1312, and depth as ,8 27 Head to toe HEAD Closer to head is Proximal Closer to toes is Distal 14

15 HEAD Measure Side to Side Identifies the degree of closure visible in the most problematic observable Stage II or higher pressure ulcer. 1. Determine which pressure ulcers are observable 2. Determine which one of the observable pressure ulcer is the most problematic 3. Report the status of the wound in M1320 7,

16 Observable refers to a wound that it not covered with non-removable dressing. Likewise, the presence of necrosis (slough/eschar) does not impact the ability to observe pressure ulcer when determining healing status. A wound that is covered with slough and/or eschar can t be staged. 7, Newly Epithelialized Epithelial tissue has completely covered the wound surface regardless of how long the pressure ulcer has be epithelialized Stage III/IV closed pressure ulcers Not appropriate for closed stage II pressure ulcers because they are not captured on OASIS 1- Fully Granulating Fully granulated but epithelial tissue has not completely covered the wound surface. Stage III/IV pressure ulcers 7,

17 2- Early/partial granulation Stage III/IV pressure ulcers Slough/eschar covers less then 25% of the wound bed 3- Not healing All open Stage II pressure Ulcers Serum filled blisters are not open and are not captured as not healing- would be captured as NA Suspected Deep Tissue Injuries NA- No observable pressure ulcer Dressing or device 7,8 33 If the only pressure ulcer the pt has is a stage II,,presenting as a serum-filled blister, the answer would be N/A, because there is no observable wound bed. 7,

18 Identifies the presence of stage I pressure ulcers NPUAP defines a Stage I ulcer as intact skin with non-blanchable redness of a localized area usually over a boney prominence. 7,8 35 Identifies the stage of the most problematic observable Stage 1 or higher pressure ulcer 1. Determine which wounds are observable 2. Determine which one of the observable pressure ulcers is the most problematic 3. Report it in M1324! 7,

19 Observable means: Not covered with a non-removable device You can visualize the wound base Most Problematic May be largest, most advanced stage, infected, most difficult to relieve pressure, or most difficult to access for treatment. 7,8 37 Unstagable pressure ulcers due to the presence of necrosis can not be staged because you cannot visualize the wound bed. If you are unable to stage the wound (Unstageable) due to necrosis or you are not allowed to remove the dressing, then M1324 will be NA- no observable pressure ulcer. 7,

20 Stage- NA Status- 3- Not Healing 39 Todd Springfield, RN, BSN, CWOCN 40 20

21 More than 40 risk assessments 17 Standardized d risk assessments e with predictive e validity studies: Braden Norton Gosnell Waterlow Bergstrom 41 Consists of six subscales 19 Sensory perception Moisture Activity Mobility Nutrition Friction/shear Total score from = very high risk 10-12= high h risk 13-14= moderate risk 15-18= low risk 19-23= no risk Reprinted with permission. Copyright Barbara Braden and Nancy Bergstrom,

22 Objective data Sensory Perception Mobility Moisture Nutrition Friction/shear Risk Assessments Subjective data that fluctuates amongst clinicians 17 Nutritional deficits Mobility Moisture Mechanical ventilation Circulatory disorders Use of vasoactive drugs Devices Drains, catheters, immobilizers Clinical Factors 43 Braden is valid when answered accuracy. Inaccurate ate assessments e leads to incomplete care planning. EMRs often do not provide guidance for Braden risk accuracy

23 Intent: Assesses the patient s ability to respond meaningfully to pain and discomfort. 2-part question Cognitive Status Cutaneous Perception Reprinted with permission. Copyright Barbara 45 Braden and Nancy Bergstrom, Completely Limited: LOC Unresponsive Does not moan, groan, or flinch, Diminished LOC or sedated 2. Very Limited: LOC Responds to painful stimulation only Minimal ability to communicate discomfort 1. Completely Limited: Cutaneous Perception Patient demonstrates limited ability to feel pain over most of the body Ex: Quadraplegia 2. Very Limited: Cutaneous Perception Inability to feel pain or discomfort on ½ of body EX: Paraplegia Hemiparesis Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale

24 1. Slightly Limited: LOC Unable to routinely express discomfort but can respond to verbal commands 2. No Impairment: LOC Responds to verbal commands Can voice discomfort independently 1. Slightly Limited: Cutaneous Perception Patient demonstrates limited ability to feel pain/discomfort in 1or 2 extremities. Ex: Hemiparesis Multiple Sclerosis Spinal Stenosis Neuropathy 2. No Impairment: Cutaneous Perception No impairment observed Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale. 47 Intent: Assesses the patient s degree to which the skin is exposed to moisture Moisture includes: Urine Feces Wound exudate Expiration Reprinted with permission. Copyright Barbara 48 Braden and Nancy Bergstrom,

25 1. Constantly Moist Constantly exposed to moisture by perspiration, urine, feces, or wound exudate. Dampness observed with each position change. Constant dribbling Autonomic dysfunction 1. Occasionally Moist Daily but infrequent moisture Nighttime incontinence Use of adult undergarments Use of moist packs 2. Often Moist Skin is moist often but not constantly. Periods of dryness between episodes of moisture Requires frequent linen changes (3 or more in 24 hours) 2. Rarely Moist Exposure is not an issue Continent patient No open skin lesions Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale. 49 Intent: Measures the patient s frequency of ambulation. Does not include bed mobility. Used to assess the degrees of risk associated with intense or prolonged pressure. Reprinted with permission. Copyright Barbara 50 Braden and Nancy Bergstrom,

26 1. Bedfast OASIS score of 6 unable on M1860 Unable to sit in chair or side of bed at all 3. Walks Occasionally OASIS score of 2 or 3 Walks 2 or more times day 2. Chairfast Oasis score of 4 or 5 on <M1860 Able to stand or walk very little. Able to sit on the side of the bed Walking is limited to 2-3 steps 4. Walks Frequently OASIS score of 0 or 1 Walks outside or around the home Able to walk a moderate distance Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale. 51 Intent: Assesses the patient s ability to change and control body position. i Bed mobility refers to the ability to change position and the patient s motivation to change and sustain position changes. Reprinted with permission. Copyright Barbara Braden and Nancy Bergstrom,

27 1. Completely Immobile Unable to independently make position changes Total dependency 2. Very Limited Makes occasional position changes but requires assistance for frequent or significant position changes. 3. Slightly Limited Can shift slightly or often independently Needs assistance to maintain or attain a position change 4. No Limitation Independent in position changes Does not require assistance or verbal reminders Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale. 53 Intent: Assessment of the patient's nutritional ii status. Includes: Oral Intake TPN/Tube Feedings Reprinted with permission. Copyright Barbara Braden and Nancy Bergstrom,

28 1. Very Poor: Oral Dietary intake is well below requirements Does not complete a full meal 2 servings of protein daily Poor fluid intake No supplements 1. Very Poor: TPN/Enteral NPO Clear liquids IVF > 5 days 2. Probably Inadequate: Oral Small portions; marginal dietary intake 3 servings of meat/dairy each day Consumes occasional supplements 2. Probably Inadequate: TPN/Enteral Liquid nutritional is sole source of supplements Takes less than recommended and/or ordered amount Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale. 55 Identifies the patient s ability and the type of assistance required to safely ambulate or propel self in a wheelchair over a variety of surfaces. 28

29 3. Adequate: Oral Occasional encouragement is needed Eats more than ½ of most meals 4 servings of protein and dairy products daily Takes supplements 4. Excellent: Oral Consumes most of each meal 4 or more servings or meat and dairy products Snacks between meals Does not require nutritional supplementation 3. Adequate: TPN/Enteral Tolerates TPN/Tube without difficulty *TPN/Enteral Feedings score 1-3. Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale. 57 Intent: Assess the patient s risk of tissue damage related to shear and friction i forces. Decreased tissue tolerance 3 categories Reprinted with permission. Copyright Barbara 58 Braden and Nancy Bergstrom,

30 1. Problem Moderate to maximum assistance with transfers OASIS score of 4-6 on M 1860 Slides down in bed or chair, requires frequent positioning Spasticity, contractures, agitation Can not be lifted off the sheets OASIS score of 1 on M Potential Problem OASIS score of 1-2 on M1610 (Incontinence) Requires minimal assistance with position changes OASIS score of 4-5 on M 1860 Occasionally slides down in chair Restraints, casts, and prosthesis 3. Potential Problem Able to life independently Maintains good position in the bed or chair. Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale. 59 The goal of the Braden Scale is to accurately predict who will develop pressure ulcers for the purpose of planning effective preventive interventions. 18 Interventions linked to risk scores

31 Institute a pressure ulcer prevention program for all at risk patients based upon pt s risk assessment score. 1) Frequent Skin Assessments 2) Pressure redistribution 3) Repositioning 4) Nutritional Assessment 5) Incontinence Care An ounce of prevention is worth a pound of management! Be PROACTIVE instead of REACTIVE! Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale. 61 Encourage frequent Educate on importance of small/frequent position position changes for all changes at least q 2 patients despite scored hours 10 risk 6 Use of pillows to off load joints. Repositioning frequency Float heels on pillow or dependent on: consider the use of heel Individual tissue tolerance suspension system while in bed. Level of activity/mobility 10 HOB at/below 30 degrees. Skin condition (Knee gatch if HOB is Treatment objectives 6 elevated.) Position changes while in w/c every hour 10 No Impairment Slightly Limited Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale

32 Educate on importance of small/frequent position changes at least q 2 hours 10 Use of pillows to off load joints. Float heels on pillow or consider the use of heel suspension system while in bed. 10 HOB at/below 30 degrees. (Knee gatch if HOB is elevated.) 10 Position changes while in w/c every 15 minutes 10 Limit w/c use to 1-2 hour intervals 10 Utilize pressure relief cushion (gel or foam w/c cushion) Draw sheet for position changes or Hoyer lift in home Very Limited Routine skin care Small frequent position changes at least q 2 hours 10 Use of pillows to off load joints. Elevate heels 10 HOB at/below 30 degrees. (Knee gatch if HOB is elevated.) 10 Position changes while in w/c every 15 minutes 10 Limit w/c use to 1-2 hour intervals Utilize pressure relief cushion (gel w/c cushion) 10 Draw sheet for position changes or Hoyer lift in home Completely Limited Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale. 63 Routine skin care as needed to keep the skin clean and dry. 10 Use skin emollients to hydrate the skin for dry skin. Rarely Moist Routine skin care as needed to keep the skin clean and dry. 10 Identify cause of moisture and correct if possible. 10 Consider incontinent care products with each episode (ph balanced cleansers, skin barriers and absorbent briefs) 10 HOB at or below 30 degrees with knee gatch if elevated 10 Treat fungal dermatitis Encourage adequate fluid intake Occasionally Moist Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale

33 Routine skin care as needed to keep the skin clean and dry. Identify cause of moisture 10 Consider incontinent care products with each episode (ph balanced cleansers, skin barriers and absorbent briefs) 1,10 HOB at or below 30 degrees with knee gatch if elevated 1,10 Treat fungal dermatitis Consider the use of an incontinence containment device. 10 Very Moist Routine skin care as needed to keep the skin clean and dry Identify cause of moisture 10 Consider incontinent care products with each episode (ph balanced cleansers, skin barriers and absorbent briefs) 1,10 HOB at or below 30 degrees with knee gatch if elevated 1,10 Treat fungal dermatitis Apply fecal/urinary containment device 10 Constantly Moist Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale. 65 Encourage/promote activity Encourage/promote activity Teach pt/cg importance of small, frequent position changes 10 PT/OT consult Walks Frequently Walks Occasionally Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale

34 Provide routine skin care No limitation Provide routine skin care Teach pt/cg importance of frequent position changes 10 Small, frequent position changes every 2 hours to reduce duration/magnitude of pressure 10 Elevate heels off bed 10 Use foam wedges to maintain position Lateral positioning 10 Use draw sheet for position changes HOB at/below 30 degrees 10 Knee gatch if HOB is elevated Position change in w/c every 15 minutes 10 Use device for transfers (trapeze, hoyer lift). 10 PT/OT consult Slightly Impaired Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale. 67 Teach pt/cg importance of small, frequent position changes Small, frequent position changes every 2 hours 10 Elevate heels off bed 10 Use foam wedges to maintain position Use draw sheet for position changes HOB at/below 30 degrees 10 Knee gatch if HOB is elevated Position change in w/c every 15 minutes 10 Limit w/c use to 1-2 hours 10 Use device for transfers (trapeze, Hoyer lf) lift). 10 Pressure redistribution surface 10 PT/OT consult Teach pt/cg importance of small, frequent position changes Small, frequent position changes every 2 hours 10 Elevate heels off bed 10 Use foam wedges to maintain position Use draw sheet for position changes 10 HOB at/below 30 degrees 10 Knee gatch if HOB is elevated Position change in w/c every 15 minutes 10 Limit w/c use to 1-2 hours 10 Use device for transfers (trapeze, Hoyer lift). 10 Pressure redistribution surface 10 PT/OT consult Very Limited Completely Limited Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale

35 Provide routine meal assistance as needed Provide routine meal assistance as needed Increase protein intake in open wounds 10 Increase calorie intake in open wounds 10 Increase fluid intake in open wounds 10 Supplement with multivitamins as needed (Vit A, C, & E) Excellent Adequate Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale. 69 Obtain prealbumin levels Obtain prealbumin Minimum of kcal per levels kg/body weight per day g/kg/day protein Assist with meals as 1 ml of fluid intake per kcal needed. per day 10 May need to assist with Provide nutritional feeding support 10 Dietician consult Offer supplements if ordered based upon lab Consider tube feedings data and oral nutritional May need to assist with supplements between feeding meals 10 Dietician consult 10 Probably Inadequate Very Poor Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale

36 Identified the presence of urinary incontinence or condition that requires urinary catheterization of any type, including indwelling or intermittent. Kilocalories= Kcal/kg/day Adequate fluid intake Vitamins & minerals with balanced diet; supplements with deficiencies Tube feedings have no effect on pressure ulcers Fluids= Assess for dehydration 72 36

37 Encourage frequent position changes and avoid moving Use a draw sheet for transfers 10 HOB at/below 30 skin over rough degrees 10 surfaces. 1,10 elevated Knee gatch if HOB Heel/elbow pads if needed Use a draw sheet for transfers HOB at/below 30 degrees 1,10 Knee gatch if HOB elevated Heel/elbow pads if needed Use of an assistive device for repositioning 1,10 No Problem Potential Problem Problem Copyright Barbara Braden and Nancy Bergstrom, Interventions based upon the Braden Scale. 73 Braden Scores should be consistent with OASIS-C scored data elements! 74 37

38 Establish practice for managing situations where elevation is maintained longer than necessary Place socks on the patients Use transparent dressings to protect heels from friction alone or in combination with socks Seamless heel protectors Place a pillow under the lower legs to Offload heels when moving the patient up in bed. If able, encourage patient to bend knees and position feet flat during position changes. Turn patient side to side to remove linens, adult briefs, and soiled incontinence pads. 75 Staff Education Training necessary on: Pressure ulcer staging OASIS-C documentation Braden Accuracy Care Plan Development Evidence-based prevention interventions Patient Education Patient education guides regarding pressure relief Clinical Support CWOCN consults for high-risk individuals CWOCN provided training programs DME referrals for at risk individuals Assess: Skin Temp Color Consistency Pain/Sensation 76 38

39 1. Association for the Advancement of Wound Care {AAWC}. (2007). Educational Images Cd. 2. Aydin, A., & Karadag, A. (2010). Assessment of nurse s knowledge and practice in prevention and management of deep tissue injury and stage 1 pressure ulcer. Journal of Wound, Ostomy Continence Nursing, 37(5): Black, J., Baharestani, M., Cuddigan, J., Dorner, B., Edsberg, L., Langemo, D., et al. (2007). National Pressure Ulcer Advisory Panel's updated pressure ulcer staging system. Dermatology Nursing, 19 (4), Bryant, R., & Nix, D. (2006). Acute and chronic wounds: Current management concepts. (3 rd ed.). St. Louis, MO: Mosby. 5. Braden,B., & Berstrom, N. (1988). Braden Scale. Retrieved June 3, 2011 from 6. Braden, B. (2001). Protocols by level of risk. Retrieved June 3, 2011 from 7. Centers for Medicare and Medicaid Services [CMS]. (2009). Oasis-c guidance manual. Retrieved January 1, 2010 from 8. Chishol, D., Krulish, L., & Best, H. (2009). Instant oasis-c answers: A CMS-based ready reference for data collectors. Redmond, WA: Author. 9. Doughty, D. (2008). Prevention and early detection of pressure ulcer in hospitalized patients. Journal of Wound, Ostomy Continence Nursing, 35(1): European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. (2009). Prevention and treatment of pressure ulcers: Quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel. 11. NPUAP. (2007). Normal Skin. Retrieved 3/1/2011 from NPUAP. (2007). Stage 1. Retrieved 3/1/2011 from NPUAP. (2007). Stage 2. Retrieved 3/1/2011 from NPUAP. (2007). Stage 3. Retrieved 3/1/2011 from NPUAP. (2007). Stage 4. Retrieved 3/1/2011 from NPUAP. (2007). Unstageable. Retrieved 3/1/2011 from NPUAP. (2007). Deep tissue injury. Retrieved 3/1/2011 from Magnan, M., & Maklebust. (2008). The effect of web-based braden scale training on the reliability and precision of braden scale pressure ulcer risk assessments. Journal of Wound, Ostomy Continence Nursing, 35(2): Serpa, L. (2011). Predictive validity of the braden scale for pressure ulcer risk in critical care patients. Rev. Latino-AM. Enfermagem; 19(1):P