Pressure Ulcer Assessments in Nursing Homes
Every nursing home must conduct a comprehensive assessment of each resident’s specific risk for skin breakdown. With hundreds of variables, systematizing such an assessment for efficient use by nursing home staff is critical. In this week’s episode, we welcome Dr. Nancy Bergstrom, who along with Dr. Barbara Braden, developed the Braden Scale for Predicting Pressure Ulcer Risk to talk about the importance of skin assessments and the myriad of variables at play.
Schenk: Hi there, welcome back to the show. My name is Rob. I will be your host this particular episode. If you are enjoying the content of the Nursing Home Abuse Podcast, please be sure to like and subscribe wherever you get your podcasts from. And if you’re watching this on YouTube, please be sure to like and subscribe, leave a comment in the comment section if you’re enjoying it or have any questions. We appreciate any feedback that you got. As a consequence of feedback, because we get a lot of questions about pressure ulcers, we wanted to have an episode dedicated to pressure ulcer assessment. We’ve talked about treatment. We’ve talked about the anatomical and physiological causes of pressure ulcers in the past. This time we wanted to really do a deeper assessment on the – assessment? We wanted to do a deeper dive on how people can be assessed for their risk for developing pressure ulcers.
One of the universal assessment tools used by nursing homes across the country is the Braden Scale, and today on the podcast, we have Dr. Nancy Bergstrom who was one of the developers of the Braden Scale, and it’s in fact, it’s called the Braden Scale but it’s copyrighted as the Braden & Bergstrom Scale. And so we were so lucky that we were able to get Dr. Bergstrom on this show to talk about pressure ulcer assessments in general but the Braden Scale in particular.
Dr. Nancy Bergstrom received her PhD from the University of Michigan. Prior to her retirement, she served as professor at the University of Nebraska Medical Center in Omaha and as the Trumbull Professor of Aging Research and Director of the Center of Aging at the University of Texas Health Science Center in Houston. That’s a mouthful. Her research for more than 30 years focused on predicting and preventing pressure ulcers. Dr. Bergstrom and Dr. Braden created the Braden Scale for predicting pressure ulcer risk and conducted numerous studies of reliability and validity and clinical utility of the Braden Scale. Dr. Bergstrom chaired the U.S Government Agency for Policy and Research Panel, creating the first guidelines for pressure ulcer prediction and prevention. More recently, she focused on clinical studies to improve patient safety through pressure ulcer prevention. And we’re again, super lucky to have her on the show. Dr. Bergstrom, welcome to the show.
Bergstrom: Thank you for having me.
Schenk: Fantastic. I am excited to have you on the show. We’ve had numerous episodes about pressure ulcers and information that families can use with regard to helping prevent the risk of pressure ulcer development in their loved ones in nursing homes. And I was excited to have you on because this is one of your areas of expertise. Within that subcategory, you are highly knowledgeable about the process by which a nursing home, a nursing facility is going to assess and evaluate an individual’s risk of developing pressure ulcers, because correct me if I’m wrong, not everybody is at the same type of risk of developing this type of wound. So if you could just, from a 40,000-foot view, when a resident comes into or is admitted into a nursing home, why is a pressure ulcer a skin integrity risk assessment, why is it important and what all is kind of involved in that process?
Why is the quality of pressure ulcer assessments important?
Bergstrom: Let me back up one sec and tell you that when I was just a student nurse and then a graduate student, I took care of people with pressure ulcers and I kept thinking why on earth can’t we prevent these instead of treating them. It just doesn’t make any sense. And as I grew in my career, [04:54] we worked together and developed an instrument to help us predict who would get a pressure ulcer, not so for predicting, but so we could prevent them. So we were really eager to find a way to prevent pressure ulcers. Just when we started this, pressure ulcers were considered, in a written article about this, the scourge of nursing homes. And so that’s where we entered the picture, wanting to decrease the incidents of pressure ulcers and remove people from being at such great risk so we could reduce the overall number of pressure ulcers in nursing homes.
Schenk: Exactly. So I guess from, like that’s why it’s important right out of the gate, like not necessarily like six weeks later, but almost right out of the gate, there’s the facility going bam-bam-bam, “Here’s a checklist.”
Schenk: So let me ask this. Is there a uniform system of assessing residents? Like would nursing home A assess a resident for pressure ulcer development in the same way that nursing home B would do that?
Are all pressure ulcer risk assessments the same?
Bergstrom: Well we would like to think that we offer the opportunity to prevent all of these. We developed the Braden Scale of predicting pressure sore risk and it was copyrighted in 1988. And over the many years, we’ve done a lot of research in this area and looked at others very widely. So our instrument is used pretty much in nursing homes around the world. So the overall goal we have was to provide a way for people to jump in and do a quick assessment about pressure ulcer risk.
Schenk: Exactly. I’m sorry, I didn’t mean to cut you off. Go ahead.
Bergstrom: Oh no, you didn’t. Go ahead.
Schenk: I was going to say you said the word “Braden Assessment.” For people out there who are not familiar with that, what does that mean? Is it the person’s name, this type of thing?
What is the Braden Scale for Predicting Pressure Sore Risk?
Bergstrom: Sure. Dr. Braden and I started working together in the early ‘80s, and she had began to develop a tool, which then we together did many, many years of NIH-funded research to describe the tool and to provide evidence of the particular validity and usefulness of the tool. So the Braden Scale, what it does is it simplifies the risk assessment. Many people will tell you a big long list of things that would lead a person to be at risk for pressure ulcers. What we’ve done is to conceptualize it so that many of those risk factors fall into one category. For instance, if somebody had limited mobility, if we were using the expanded checklist, we might go through something like stroke, [08:22], fractured hip, arthritis, paraplegia, whatever. But what we look at is mobility – can this person move for an activity? Can they get out of bed? And so we try to simplify it down into six small subscales that not only identify the risk factors but attempt to assign a level of severity of the risk factor, so that can guide clinical practice.
Schenk: And just for our listeners, I have to ask questions even though I know the answer to them, but just letting you know to the listeners out there that Dr. Bergstrom and Dr Braden in this Braden Assessment is kind of like the gold standard. It is a widely used tool and she’s being very humble, but it’s been critical in many nursing homes across the country in assessing individuals for skin integrity. But Dr. Bergstrom, you had mentioned assessing mobility, these types of things. Can you, just from a broad standpoint, what are the other categories? So for example, would someone’s cognitive capacity, would someone’s mental capacity, would that relate into the assessment? And then from there, how does that relate to the final analysis? Is it a numbered thing, like this person is a 10 out of 10 or is it like high, medium, low, this type of thing? Can you kind of go through these categories and kind of explain at the end of the day, what is that document going to tell us?
How does the Braden Scale work?
Bergstrom: Sure, I’d be happy to do that. Well first of all, let’s talk about how we conceptualize this whole big area. So we boiled it down to two things in the end – how much pressure is being applied to the skin by the bony prominences and the surfaces upon which the person is lying? And we’re going to say that not everybody is alike. Everybody’s tissue may have a different response. So we call this tissue tolerance. So I almost wish I could send you one of our conceptualizing worksheets – it might be easier to follow.
But pressure, yes, we have three categories to it. One is sensory perception, another mobility and activity. Sensory perception is can this person feel, but it also says if they can feel, are they conscious enough to seek help if they need it? So a mental status, whether they’re confused or whether they’re not able to response at all to stimuli does play a part. So does the ability to feel and perceive. So that’s like one risk factor and there are like 54. Mobility is the ability to even turn themselves in bed, may influence whether or not they can release pressure naturally by themselves. The other risk factor then is activity – can that person get up and move about on their own? So all those things are determinants of whether or not they could be exposed to pressure.
And then we have the matter of tissue tolerance – can much does the individual characteristic have a factor in how much pressure can be tolerated? And we look at this as well from the inside, from the extrinsic factors, from the outside. It might be things like moisture. Is the person wet a lot, whether it happens from incontinence, perspiration, wet because it’s hot in a nursing home or whatever? Moisture decreases the ability of tissue to tolerate pressure. Also something known as friction and shear, which is real common because many nursing home patients slide down in bed and so we tend to just pull them back up. Well the moist skin in the sheet creates a fair amount of friction and it can also lead to disruption of the integrity. And I can talk about that later.
But there are also intrinsic factors, just things from within, like how has the person been eating? There are some nutritional things that are particularly important. Other things like increased age – people sometimes have changes to their skin and sub-tissue and tissue. But other things would be factors that influence blood flow and blood pressure, so things like if a person has low blood pressure, if they’re having other hypothetical factors beyond the arterial pressure would be emotional stress. We know that stress is related to increase in pressure ulcers. Smoking certainly is a factor and skin temperature. All of these things are not necessarily in the Braden Scale, but we do look for both intrinsic and extrinsic factors and we do try to quantify nutrition.
Schenk: Got you. That all makes sense. There are so many factors. I think you said like 54 factors or something like that.
Bergstrom: Yeah, maybe 100.
Schenk: Yeah, at least. So take me through then once you have your RN or your CNA, whoever it is, that’s crunching numbers or whatever the case may be, at the end of the day, what’s the result? Is it a score? And if it’s a score, what does it mean? How is the rating actually computed?
How does the Braden Scale produce a score?
Bergstrom: Sure. So let me say the other feature of this is what I told you about were just the main risk factors. Then we tend to quantify them from one to four, so that we have a descriptor that shows the increasing severities. A score of one is like the lowest. This would be, for instance, unconsciousness – a person that just could not, is not unconscious or they have no ability to feel pain, and that would be a score of one. A score of four might be their sensory abilities are perfectly intact. They can both feel discomfort and if they need to, they can call someone. So on that scale, a person would get a score from one being the lowest to four. For each of the subscales, we attempt to quantify in this manner from lowest to highest, meaning the lowest score here is the greatest amount of risk. So at the end of their whole assessment where we go subscale by subscale, we come up with a total score. And the final total points are 23. I think I just got that wrong. Anyways…
Schenk: If it’s not that, then it’s close to it, I think.
Bergstrom: It’s 21. It’s 21. Sorry, 21. So the final score possible would be 21. So someone that has scored from 18 to 21 we figure are not too much at risk for pressure ulcers. We call this mild risk. This does not mean people with higher scores, like from 21 to 23, the maximum possible, could not get a pressure ulcer. It’s just they’re less likely to. But we need to consider all the individual subscale scores because in the end, we’re going to make our care plan based on this score, this subscale score.
Schenk: That makes sense.
Bergstrom: And then let me just say scores of like 13 to 15 would be considered moderate. Scores from 10 to 12 would be considered high risk. And nine or below would be very high risk. And then so that type of scoring really only helps you to understand who probably needs the most attention right away, but that doesn’t mean that people with even higher scores don’t need specific attention. If the nutrition is terrible and you see that in the subscale score, that would be something that would be implemented.
Can non-physicians use the Braden Scale for pressure ulcer risk assessment?
Schenk: Wow, okay. So as Dr. Bergstrom is talking about the different categories and then within the categories, the scoring processes of being one through four and then crunching those numbers and coming up with an ultimate score that would assign you as a high, medium or mild risk for pressure ulcers, but it sounds like this complicated process. However, if you’ve actually seen one of these documents, and I would recommend that if your loved one is in a nursing home, you have the full right to review medical records. You can ask for them. You can ask for the care plan. And within the care plan, within the assessments, you can actually get this document if they’re in fact using the Braden Scale, which they probably are. But you’ll be amazed at despite what seems to be an extremely complicated set of variables that the way Dr. Bergstrom and Dr. Braden have laid this test out, laid the assessment out, it’s actually quite user friendly. So I can imagine, Dr. Bergstrom, that that was very difficult to go from, “Here are the 54 factors” or “Here are the thousands of things that could put you at risk, here we are, we’re going to weight it and we’re going to scale it but also make it easy for the person doing the assessment to understand it because not everybody is a medical doctor.”
Bergstrom: That’s right.
Schenk: Can you speak to that? Like how difficult was that?
How is the Braden Scale “user friendly?”
Bergstrom: Well you know, we tried to make it simple so most people could use it. In fact, we tried it in three different nursing home trials before we ever published the paper for the first time. And we found that the tool could be fairly reliably used, that is people picking up the tool for the first time, if two people compared their results after reading the words and scoring someone they knew, this would fairly reliable if it was two RNs. But we found that nursing assistants and, to some degree, LPNs, because if they get on the subject and didn’t have the training, just could not be quite as accurate because there are some nuances in the tool that a trained person would need to understand. So there are trainings. There are ways people can train staff to improve their ability to score this tool. And we recommend that facilities that are going to use this tool also work out what they’re going to do for interventions related to each subscale score.
Schenk: Exactly. So let me ask this. So we’ve been talking about using this assessment tool as a means of helping put into place a care plan at the beginning of the stay, at the admission. But correct me if I’m wrong, but typically this assessment would need to be done either on a regular basis or particularly after a change of conditions. So for example, if the individual develops a pressure ulcer in spite of having this assessment done with a care plan put in place, can you speak to how often should a facility be doing this type of assessment?
How often should a nursing home conduct a pressure ulcer assessment?
Bergstrom: Yes. Let me say first of all, we think this should be done right at admission, because after all, it’s about care planning. You’re not trying to predict if they’re getting a pressure ulcer. You’re trying to plan the care the person needs so they do not get one. So have always said it should be done right on admission as soon as possible. And then we recommend because there are things the nurse won’t know, they don’t know how they eat, how well they eat at that point, they don’t know if they’re going to be incontinent, so we recommend they also be reassessed a day or two later and then at the end of the first week as you really have a fuller understanding of what this person is able to do and what their needs might be. And so we have this recommendation that we’ve made and I don’t know how firmly it’s followed, but then we also go on to say it’d be good to evaluate at the end of the month and then quarterly, whenever the MDS records are updated.
But there are caveats to this. So once you assess somebody, when do you need to reassess? And this would be the same no matter here at home or they’re in a nursing home or ICU. And that would be when there is a change in condition. So a change in condition could be something like the person stops eating for a couple days. Somebody may stop for a day and may just have a small amount of water or something, juice, but if this persists for more than a couple days, we need to jump right in here and start improving the nutrition one way or another. So we do think that one change – another would be are they running a fever? Or in older people, sometimes they get real hypothermic when your blood pressure gets low. That would be another change in condition. If they have a cold or the flu or they’re discharged to a hospital or there’s some big shock in their life, the loss of a loved one causing extreme stress, all those things might mean that we should reassess and look at if the person’s wound care has changed.
What is the recommended schedule for conducting a pressure ulcer risk assessment?
Schenk: That makes sense. If I understand it correctly, you talked about it’s important. And obviously there’s no set standard that they have to do. It’s just if they do it, but at least within the first 48 hours, preferably by the end of that first week, maybe by the end of the month, that first month, and then quarterly along with – and just for the listeners, we have had an episode or two about the MDS, which is a minimum data set, which is kind of like an assessment that’s required by the nursing home if they want to get Medicaid/Medicare money, where they go through and they document and assess not just skin integrity but other factors of the care required for a resident. But you’re saying, if I understand, Dr. Bergstrom, that you would need to do it again then and so quarterly after that. So that makes sense.
Bergstrom: Yes. But the big thing is it should be right on admission. I did a study with a couple of masters students one year where we looked at [25:09]. And the [25:11] surveyed that were supposed to be coming in alive until like 48 hours later, at which time a large number of residents already had some skin changes. And so it’s important to do it right away and do the assessment, start the care planning immediately.
Schenk: Yeah, and I think at least some people have heard you because within the last couple of years, CMS is now requiring a baseline care plan and an assessment done in 48 hours, which was not always the case. Usually before that, it is my understanding that nursing homes had two weeks, which a lot of things can happen in a shift let alone two weeks.
Bergstrom: That’s for sure. And especially when people go into nursing homes, rehab centers, sometimes they’re under a great deal of stress in that first week. You have to look at it. So if they’ve been in the hospital and had major surgery or [26:11] rehabilitation, they could have a pretty high cortisol level. And this is a predisposing factor to developing pressure ulcers. So we need to really pay close attention. Also the psychological stress of going to a nursing home for the first time where people are wondering, “Oh, what am I doing here? How long am I going to be here?” all of this I think adds to a layer of stress in the first two weeks. And then so we need to pay a lot of attention to people while we’re getting ready to know them.
How does blood pressure affect pressure ulcer development?
Schenk: That makes sense. Thank you for that. So in the last few minutes, Dr. Bergstrom, you had mentioned a couple of things that I think are extremely interesting that I think at least for me, it would not have been apparent to me before I got into this line of work. But you mentioned blood pressures and body temperatures as possible risk factors for pressure ulcer development. Can you kind of explore that a little bit? What is that correlation?
Bergstrom: Yes. Well low blood pressure actually – a lot of older people have low blood pressure, blood isn’t being transferred effectively through the vascular system, so sometimes they’re even colder and so forth. So that reduced blood flow can be a risk factor of sorts. I will say we were surprised also to find out high blood pressure that is not even high, like 130 or more, was somewhat protective in developing pressure ulcers, but it’s not going to save the game. It’s somewhat protective. So yes, those become factors. If the temperature is increased a lot, the individual may have an infectious process going on, but it also indicates that there can be some metabolic changes. The capillaries may actually increase to meet the needs of the body during an infection inflammatory process. So this can also be considered a factor.
Can I add one thing that I would like to say to families of nursing home residents? Can I?
Schenk: Go ahead. Yes, absolutely.
What can families do to help their loved ones reduce the risk of pressure ulcer development?
Bergstrom: Okay. So you talked in a previous podcast about NursingHome.gov, and I would like to say if you’re looking at nursing homes, one of the quality measures that are reflected on NursingHome.gov is the incidents of pressure ulcers in nursing facilities. So that’s a good place for anybody to look if they’re wondering about their nursing home their family member’s in, how that compares to the state and the nation in terms of statistics. And another personal note is that family members play a really important part in pressure ulcer prevention just by their presence and by the questions they ask. And so it is important to be involved. When my mother lived in a nursing home, she had already gotten dementia. I lived in Nebraska, she lived in Michigan. What can you do about that? And the answer in my case is a member of her church visited her every single day and gave skin assessments for me. And the nursing home did not like this – she would turn my mother and look at her back and look at her heel and help feed her – until I explained she is my agent. She is my eye and ear because I cannot be there. So to me, I think this is a big, important part in helping nursing home residents and helping staff who do really want to take good care of patients, but if they have another set of hands and another set of eyes is also useful.
Schenk: Thank you for sharing that story. And also thank you for having listened to another episode. We’re flattered by that.
Bergstrom: I’ve listened to four episodes.
Schenk: Well thank you very much. So yes, and I’m glad that you said that because typically I like to ask what family members can do with the information you’ve provided, and that’s one of the reoccurring themes is be active, involved. To the extent you can get people moving around, do that. So thank you for that.
I think that’s something that people don’t realize it, that even at the end of the day, we talked about this in the last podcast where it even has a psychological effect where if you’re there, from a spiritual, from an emotional standpoint, when you’ve got somebody there that’s in your corner, I don’t know, it’s like your body does better. Your whole – the physiological component of it, I think, you have a better chance when you have somebody that’s your cheerleader.
Bergstrom: Yeah, I agree with that. And it’s not bad to ask what the Braden Scale score is and what they’re doing. Not every facility uses the Braden Scale, but they should have some form of assessment and be able to tell you what they’re doing by way of care plan to prevent problems.
Schenk: That’s exactly right. That’s what we – and for listeners that are interested, we’ve had a podcast about how to – first of all, how to know who’s doing what, so who to ask the questions to. Then if you get any kind of pushback, which hopefully you won’t, but if you do, how to politely through a written request get the records. And from the records, understanding how to read the records, and as Dr. Bergstrom said, you are perfectly allowed, absolutely allowed if you’re your loved one’s representative to get that information. It’s not like it’s protected. If you’re the actual representative, you can ask, “What is the assessment?” And based on if the person is a high risk, low risk, “What are you guys doing? What are the what’s called interventions that you guys are doing to prevent this?” So that’s super important information. And Dr. Bergstrom, thank you so much for sharing your story, sharing your information. We talk about the Braden Scale often on this program and it’s just an honor to have somebody who developed the thing to be on here. So we appreciate your time and thank you so much.
Bergstrom: Certainly. Thank you for inviting me.
Schenk: And again, the Braden Scale is universally used in many nursing homes. So again, we are super happy to have had Dr. Bergstrom on who is a part of the process of creating and implementing this and doing the studies behind it. What a great person. It’s always great to have experts on this program to talk about these things. Obviously Will and I can’t do it all by ourselves or anything like that, so it’s good to have a conversation with the people that are behind the tools that we talk about on this program. So hats off to her.
If you enjoyed the content, be sure to like and subscribe wherever you get your podcast from. It would also help us if you’re watching this on the YouTube to subscribe and like. Leave a comment if you’ve enjoyed it. New episodes twice a month, I believe, yeah, every other week, new episodes for the time being. At any rate, my name is Rob and on behalf of Will, my law partner who is usually my co-host, and Dr. Bergstrom, we will see you next time.