1 Supplementing the Braden scale for pressure ulcer risk among medical inpatients: the contribution of self-reported symptoms and standard laboratory tests. Ingrid Johansen Skogestad, MSc, RN*; Liv Martinsen, RN; Tove Elisabet Børsting, Assistant Professor, MSc, Paediatric Nurse, RN; Tove Irene Granheim; Eirin Sigurdssøn Ludvigsen MNc, CCN, RN; Caryl L. Gay, PhD, Researcher; Anners Lerdal, PhD, RN, Professor and Research Director Word count: 5504 IJS (*Corresponding author): Medical Department, Lovisenberg Diakonale Hospital, Lovisenberggata 17, N-0456 Oslo, Norway Telephone +4723226040. Fax: +4723225881 E-mail: [email protected]LM Medical Department, Lovisenberg Diakonale Hospital, Lovisenberggata 17, N-0456 Oslo, Norway Telephone +4723225870. Fax: +4723225881 E-mail: [email protected]TEB Lovisenberg Diaconal University College, Lovisenberggata 15b, N-0456 Oslo, Norway Telephone 92447764. E-mail: [email protected]TIG & ESL Surgical Department, Lovisenberg Diakonale Hospital, Lovisenberggata 17, N-0456 Oslo, Norway Telephone +4723226291/6353 E-mail: [email protected]& [email protected]CLG Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, USA and Department of Research and Development, Lovisenberg Diakonale Hospital, N-0456 Oslo, Norway. 2 Koret Way, Room N411Y, Box 0606, San Francisco CA, 94143-0606. Telephone: +14154764435 Fax: +14157532161 E-mail: [email protected]AL Dept. of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Norway and Department of Research and Development, Lovisenberg Diakonale Hospital, Lovisenberggata 17, N-0456 Oslo, Norway. Telephone: +4723225000, Fax: +4723225023, E-mail: [email protected]Acknowledgements Anne Marit Tangen, Lars Vasli, Ellen-Anne Alvin, Tove Mosvold, Magne Hustavenes, Gro Mikkelsen, Magnus Tarangen, Einar Amli, Laila Randen Stenrud, Heidi Irene Hammerstad, Andreas Grønbeck, Reidun Grimsbø, Caroline Hammer, Margrete Bjørkhaug, Nina Kristiansen, Ingrid Holter, Leif Brunsvik. This study was funded by Lovisenberg Diakonale University College and Lovisenberg Diakonale Hospital. Contributions Study design: AL, TIG; data collection and analysis: IJS, LM, TEB, TIG, ESL, CG, AL; manuscript preparation: IJS, LM, TEB, TIG, ESL, CG, AL Conflict of interest The authors declare no financial or personal interests that could bias the work.
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Supplementing the Braden scale for pressure ulcer risk among medical inpatients: the contribution of self-reported symptoms and standard laboratory tests. Ingrid Johansen Skogestad, MSc, RN*; Liv Martinsen, RN; Tove Elisabet Børsting, Assistant Professor, MSc, Paediatric Nurse, RN; Tove Irene Granheim; Eirin Sigurdssøn Ludvigsen MNc, CCN, RN; Caryl L. Gay, PhD, Researcher; Anners Lerdal, PhD, RN, Professor and Research Director Word count: 5504
IJS (*Corresponding author): Medical Department, Lovisenberg Diakonale Hospital, Lovisenberggata 17, N-0456 Oslo, Norway Telephone +4723226040. Fax: +4723225881 E-mail: [email protected] LM Medical Department, Lovisenberg Diakonale Hospital, Lovisenberggata 17, N-0456 Oslo, Norway Telephone +4723225870. Fax: +4723225881 E-mail: [email protected] TEB Lovisenberg Diaconal University College, Lovisenberggata 15b, N-0456 Oslo, Norway Telephone 92447764. E-mail: [email protected] TIG & ESL Surgical Department, Lovisenberg Diakonale Hospital, Lovisenberggata 17, N-0456 Oslo, Norway Telephone +4723226291/6353 E-mail: [email protected] & [email protected] CLG Department of Family Health Care Nursing, School of Nursing, University of California, San Francisco, USA and Department of Research and Development, Lovisenberg Diakonale Hospital, N-0456 Oslo, Norway. 2 Koret Way, Room N411Y, Box 0606, San Francisco CA, 94143-0606. Telephone: +14154764435 Fax: +14157532161 E-mail: [email protected] AL Dept. of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Norway and Department of Research and Development, Lovisenberg Diakonale Hospital, Lovisenberggata 17, N-0456 Oslo, Norway. Telephone: +4723225000, Fax: +4723225023, E-mail: [email protected] Acknowledgements
Anne Marit Tangen, Lars Vasli, Ellen-Anne Alvin, Tove Mosvold, Magne Hustavenes, Gro Mikkelsen, Magnus Tarangen, Einar Amli, Laila Randen Stenrud, Heidi Irene Hammerstad, Andreas Grønbeck, Reidun Grimsbø, Caroline Hammer, Margrete Bjørkhaug, Nina Kristiansen, Ingrid Holter, Leif Brunsvik.
This study was funded by Lovisenberg Diakonale University College and Lovisenberg Diakonale Hospital.
Contributions
Study design: AL, TIG; data collection and analysis: IJS, LM, TEB, TIG, ESL, CG, AL; manuscript preparation: IJS, LM, TEB, TIG, ESL, CG, AL
Conflict of interest
The authors declare no financial or personal interests that could bias the work.
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Supplementing the Braden scale for pressure ulcer risk among medical inpatients:
the contribution of self-reported symptoms and standard laboratory tests.
ABSTRACT
Aims and objectives. To evaluate medical inpatients’ symptom experience and selected laboratory
blood results as indicators of their pressure ulcer risk as measured by the Braden scale.
Background. Pressure ulcers reduce quality of life and increase treatment costs. The prevalence of
pressure ulcers is 6-23% in hospital populations, but literature suggests that most pressure ulcers are
avoidable.
Design. Prosepective, cross-sectional survey.
Methods. 328 patients admitted to medical wards in an acute hospital in Oslo, Norway consented to
participate. Data were collected on 10 days between 2012 and 2014 by registered nurses and nursing
students. Pressure ulcer risk was assessed using the Braden Scale, and scores <19 indicated pressure
ulcer risk. Skin examinations were categorized as normal or stages I-IV using established definitions.
Comorbidities were collected by self-report. Self-reported symptom occurrence and distress were
measured with 15 items from the Memorial Symptom Assessment Scale, and pain was assessed using
two numeric rating scales. Admission laboratory data were collected from medical records.
Results. Prevalence of pressure ulcers was 11.9%, and 20.4% of patients were identified as being at risk
for developing pressure ulcers. Multivariable analysis showed that pressure ulcer risk was positively
associated with age ≥80 years, vomiting, severe pain at rest, urination problems, shortness of breath and
low albumin, and was negatively associated with nervousness.
Conclusion. Our study indicates that using patient-reported symptoms and standard laboratory results as
supplemental indicators of pressure ulcer risk may improve identification of vulnerable patients, but
replication of these findings in other study samples is needed.
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Relevance to clinical practice.
• Nurses play a key role in preventing pressure ulcers during hospitalization. A better
understanding of the underlying mechanisms may improve the quality of care.
• Knowledge about symptoms associated with pressure ulcer risk may contribute to a faster
Note. 16 patients had missing data for the skin examination and were excluded from this analysis. Significant statistics (p<.05) are presented in bold type. * The non-risk group had Braden scores of 19-23, while the at-risk group had scores of 13-18.
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Table 2. Sample characteristics by pressure ulcer risk
Total Sample
(N=328)
Pressure Ulcer Risk Group* Statistics Non-risk
(n=261) At-risk (n=67)
Gender Male Female
(=328) 169 (52%) 159 (48%)
135 (80%) 126 (79%)
34 (20%) 33 (21%)
X2(1)=0.02, p=.886
Age, years Mean (SD) Range Category, n (%) <65 years 65-79 years ≥80 years
(n=328) 62.7 (18.0) 20 – 100
160 (49%) 96 (29%) 72 (22%)
60.7 (19.1) 20 – 100
139 (87%) 75 (78%) 47 (65%)
70.8 (18.0)
23 – 99
21 (13%) 21 (22%) 25 (35%)
t(326)=3.91, p<.001
X2(2)=14.4, p=.001
ref OR = 1.85, p=.070 OR = 3.52, p<.001
Length of stay Mean (SD) Median Range
6.2 (4.2)
5 1 – 30
5.9 (4.1)
6 1 – 30
7.1 (4.7)
5 1 – 23
t(321)=1.95, p=.052
MWU p=.019
Body mass index Mean (SD) Range Category, n (%) <20 ≥20
(n=323) 24.9 (6.1)
13.6 – 56.6
63 (20%) 260 (80%)
25.2 (5.9)
14.0 – 56.6
45 (71%) 215 (83%)
23.9 (6.6)
13.6 – 46.9
18 (29%) 45 (17%)
t(321)=1.45, p=.149
X2(1)=4.10, p=.043
Laboratory values Hemoglobin, g/dL Mean (SD) Category, n (%) Low (<12) Normal (≥12)
(n=285) 12.23 (2.04)
171 (60%) 114 (40%)
(n=226) 12.41 (1.99)
144 (84.2%) 82 (71.9%)
(n=59) 11.55 (2.09)
27 (15.8%) 32 (28.1%)
t(283)=2.93, p=.004 X2(1)=6.28, p=.012
Hematocrit (%) Mean (SD) Category, n (%) Low (<35%) Normal (≥35%)
(=241) 38.02 (5.76)
55 (23%) 186 (77%)
(n=195) 38.36 (5.73)
40 (73%) 155 (83%)
(n=46) 36.59 (5.71)
15 (27%) 31 (17%)
t(239)=1.89, p=.060 X2(1)=3.09, p=.079
Albumin, g/L Mean (SD) Category, n (%) Low (<35) Normal (≥35)
(n=261) 39.54 (5.69)
48 (18%) 213 (82%)
(n=211) 40.11 (5.41)
30 (63%) 181 (85%)
(n=50) 37.11 (6.20)
18 (37%) 32 (15%)
t(259)=3.44, p=.001 X2(1)=12.8, p<.001
C-reactive protein, mg/L Mean (SD) Category, n (%) Normal (<10) High (≥10)
(n=283) 53.45 (83.67)
111 (39%) 172 (61%)
(n=222) 46.54 (79.74)
100 (90%) 122 (71%)
(n=61) 78.57 (93.11)
11 (10%) 50 (29%)
t(281)=2.68, p=.008 X2(1)=14.6, p<.001
Comorbidities* Current fracture No Yes
(n=306) 279 (91%) 27 (9%)
230 (82%) 18 (67%)
49 (19%) 9 (33%)
X2(1)=3.99, p=.046
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Note. Significant statistics (p<.05) are presented in bold type. * The following 11 comorbidities were unrelated to pressure ulcer risk: cardiovascular disease, pulmonary disease, cancer, gastro-intestinal disease, muscular-skeletal disease, neurological disease, psychiatric disease, significant vision loss, significant hearing loss, diabetes mellitus, and other comorbid condition. The 9 patients reporting cognitive impairment were excluded from the analysis, and cognitive impairment was not evaluated as a comorbidity.
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Table 3. Significant associations between pressure ulcer risk and patient-reported symptoms (N=328)
Total Sample (N=328)
Pressure Ulcer Risk Group Statistics Non-risk
(n=261) At-risk (n=67)
PAIN Pain at rest Mean (SD) Category, n (%) Low-Moderate (0-7) Severe (7-10)
(n=326) 2.97 (2.86)
283 (87%) 43 (13%)
(n=259) 2.73 (2.65)
233 (82%) 26 (60%)
(n=67) 3.87 (3.44)
50 (18%) 17 (40%)
t(87*)=2.68, p=.014 X2(1)=10.9, p=.001
Pain in activity Mean (SD) Category, n (%) Low-Moderate (0-7) Severe (7-10)
(n=324) 3.39 (3.02)
264 (81%) 60 (19%)
(n=257) 3.08 (2.88)
218 (83%) 39 (65%)
(n=67) 4.57 (3.26)
46 (17%) 21 (35%)
t(322)=3.66, p<.001 X2(1)=9.21, p=.002
OCCURRENCE OF OTHER SYMPTOMS
Nervousness No Yes
(n=322) 150 (47%) 172 (53%)
110 (73%) 146 (85%)
40 (27%) 26 (15%)
X2(1)=6.56, p=.010
Drowsy No Yes
(n=322) 76 (24%) 246 (76%)
66 (87%) 189 (77%)
10 (13%) 57 (23%)
X2(1)=3.53, p=.060
Urination problems No Yes
(n=316) 188 (59%) 128 (41%)
158 (84%) 92 (72%)
30 (16%) 36 (28%)
X2(1)=6.82, p=.009
Swelling of arms/legs No Yes
(n=321) 183 (57%) 138 (43%)
154 (84%) 102 (74%)
29 (16%) 36 (26%)
X2(1)=5.11, p=.024
DISTRESS DUE TO OTHER SYMPTOMS
Urination problems No/low distress High distress
(n=316) 280 (89%) 36 (11%)
230 (82%) 20 (56%)
50 (18%) 16(44%)
X2(1)=13.6, p<.001
Vomiting No/low distress High distress
(n=322) 303 (94%) 19 (6%)
245 (81%) 10 (53%)
58 (19%) 9 (47%)
Fisher’s Exact p=.007
Shortness of breath No/low distress High distress
(n=321) 238 (74%) 83 (26%)
197 (83%) 59 (71%)
41 (17%) 24 (29%)
X2(1)=5.21, p=.023
Note: The following 9 symptoms were unrelated to pressure risk and are not reported in this table: concentration, lack of energy, nausea, numbness/tingling in hands/feet, sleep problems, diarrhea, itching, dizziness, and skin changes. Significant statistics (p<.05) are presented in bold type. * Separate variance t-test with adjusted degrees of freedom due to unequal variances.
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Table 4. Multivariate model predicting pressure ulcer risk Predictors Odds Ratio 95% CI p Female gender (ref: male) 1.49 0.69, 3.22 .315 Age in years (ref: <65)
65-74 ≥80
1.18 4.67
0.44, 3.14
1.86, 11.72
.001
.739
.001 Lab values
Low albumin (<35g/L) 4.06 1.79, 9.18 .001 Symptoms
Note. Overall model is significant: X2(9)=62.5, p<.001. Dependent variable = pressure ulcer risk group. The following variables were evaluated for inclusion in the model but were excluded due to non-significance: length of hospital stay, BMI, hemoglobin<12, hematocrit<35%, CRP<10, count of comorbidities, comorbid fracture, severe pain in activity, occurrence of drowsiness and swelling, and distress due to urination problems.
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