Introduction Pressure ulcers are very common in chronic and acute care. "A pressure ulcer is an injury to the skin that occurs when a patient lies or sits too long in the same position. The pressure keeps blood from getting to the tissue, causing cells to die and the skin to break down" (stoppain.org). As the tissue dies, an open sore forms, and this can even be painful or become infected where in severe cases, the muscle, tendon, or bone may begin to show. Pressure ulcers usually occur on bony areas of the body, such as the tailbone, back, buttocks, back of the head, elbows, heels, hips, and shoulders. The patients that are high risk for pressure ulcers are the patients that are unable to ambulate. According to Defloor and Grypdonck, the first pressure ulcer assessment was designed and tested in 1962, which was the Norton Scale. According to this scale, each item is scored on a four-point scale, where the minimum score is a 5 and the maximum score is a 20. This scale has been tested in particularly older patients. Since the 1980s more scales have developed and at least 38 alternative risk assessment scales have been described in the literature. The most frequently used scale in research is the Braden scale. This scale consists of six items which are activity, sensory perception, moisture, mobility, shear and nutritional status. The scores on this scale vary between 6 and 23 where the original cut-off point is 16. Defloor and Grypdonck researched the American National Pressure Ulcer Advisory Panel, where they found that the ideal at risk assessment tool should have a high specificity, be easy to use, have a high sensitivity and have agood predictive value. Sensitivity is the proportion of those with the condition who have a positive test (Defloor 2005). On the contrary, specificity is the extent to which the absence of a characteristic is correctly classified or the proportion of those without the condition who have a negative test (Defloor 2005). The use of effective prevention will decrease the pressure ulcer incidence and will alter the sensitivity and the specificity for the risk assessment scales. The influence exerted on sensitivity and specificity would be real, but unpredictable depending on the effectiveness of the preventive measures, the use of preventive measures in patients really at risk of developing pressure ulcers and the correct identification of at risk patients by those using preventive measures (Defloor 2005).
Problem Statement Pressure ulcers have plagued the nursing world for years, and although preventable they are ever present. The knowledge of the pressure ulcer prevention has increased over past decades, but their occurrence remains a significant clinical problem (O'Tuathail 2011).
Statement of Purpose of the Evidence-Based Practice The purpose of this evidence-based practice was to observe the effectiveness of the Braden and Norton scale. These scales have became an essential part of pressure ulcer prevention and management, so there should be various clinical studies to support the reasoning for relying on risk assessment tools. So, in an effort to inspect the effectiveness of risk assessment scales, such as the Braden and Norton scale, studies are being conducted to test their reliability, because these risk assessment scales could be contributing to factors associated with an over diagnosis or an under diagnosis of patients with skin breakdown.
Literature Review Despite the huge numbers of preventive measures, such as pressure ulcer risk assessment scales, they are still very prevalent in the healthcare field; so, the effectiveness of these skills should be questioned. Tom Defloor and Maria Grypdonck, 2005, aimed a quantitative study of one-thousand seven hundred and seventy-two participants, “to compare the predictive value of two pressure ulcer risk assessment scales (Braden and Norton) and of clinical judgment. The results of this study concluded that the effectiveness of the Braden and the Norton scales seems to be low and new scales should be developed,” (Defloor & Grypdonck, 2005). Joan Webster, Kerrie Coleman, Alison Mudge, Louise Marquart, Glenn Gardner, Monica Stankiewicz, Julie Kirby, Catherine Vellacott, , 2011, also conducted a quantitative study with one-thousand and two-hundred and three participants “to evaluate the effectiveness of two pressure-ulcer screening tools, Braden and Norton scale, against clinical judgment in preventing pressure ulcers. In conclusion, the authors found no evidence to show that two common pressure-ulcer risk-assessment tools are superior to clinical judgment to prevent pressure injury. Resources associated with use of these tools might be better spent on careful daily skin inspection and improving management targeted at specific risk,” (Webster, Coleman, Mudge, Marquart, Gardner, Stankiewicz, & Vellacott, 2011). In addition, Anthony Don, PapanikolaouHYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=%22Papanikolaou%20P%22%5BAuthor%5D" Pearson, ParboteeahHYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed?term=%22Parboteeah%20S%22%5BAuthor%5D" Song, and Saleh Martin, 2009, conducted a quantitative study to test the validity of pressure ulcer risk assessment scales. “They came to the conclusion that while the scales are probably reliable, and do assess risk, many of the components of risk assessment scales are not predictive of pressure ulcers, there are other variables that are routinely available to clinicians that give additional predictive power, the importance of components is not accurately reflected by their range of values, components are correlated and some components may be removed with no loss of predictive power, and there is no evidence the use of risk assessment scales reduces pressure ulcer incidence. The complexity of risk assessment scales does not appear to be warranted, and there is evidence that clinical judgment is as effective in assessing risk as risk assessment scales,” (Don, Pearson, Song, & Martin, 2009).
Key Findings/Clinical Findings “Pressure ulcers are a huge concern for health professionals. They cause suffering and frustration to patients, they reduce quality of life, they are associated with increased morbidity, they are a huge financial burden on any healthcare system, and they carry the underlying connotations of neglect, mismanagement, feelings of failure and guilt on the part of the health professional” (O’Tuathail & Taqi 2011). To prevent and manage pressure ulcers, and identify patients at risk nurses use risk assessment scales such as the Braden scale and the Norton Scale. In the research study “Pressure ulcers: validation of two risk assessment scales” done by Tom Defloor and Maria Grypdonck they compared the value of the Braden and Norton assessment scale and of clinical judgment. In this study, two nurses were trained to use the Braden and Norton scale. They scored their patients twice each week over a four week period. 314 patients were randomly selected and assigned to the “turning group”. Within this group, patients with a Braden score of