Braden Scale falls short on dark-skinned patients

Clinicians not trained to assess dark skin

Anyone involved in wound care soon learns of the Braden Scale for Predicting Pressure Sore Risk. The scale, developed by clinicians Barbara Braden and Nancy Bergstrom, is used widely by clinicians to assess patients for the risk of developing pressure ulcers. But it seems that few clinicians, if any, have questioned its value for application to darker-skinned patients.

The potential problem came in a roundabout way to the attention of Courtney Lyder, RN, MS, ND, CGNP, associate professor and coordinator of the Gerontological Nurse Practitioner Program at Yale University School of Nursing in New Haven, CT.

yder started to consider the possibility that the Braden Scale might not be valid for darker-skinned patients quite by accident after she applied to the National Institutes of Health for a grant to conduct research while pursuing her advanced nursing degree. The agency returned the application with several comments. One noted the possibility that the Braden Scale may not work well for dark-skinned people. Lyder had never considered the matter before, but she turned her attention to finding the answer after she completed her advanced degree.

After conducting a prospective pilot study involving 36 patients age 75 or older in an acute-care setting, Lyder found evidence that the Braden Scale was not predictive for either blacks or Hispanics using the cut-off level on the Braden Scale of 16 or below. In a subsequent larger study involving 74 elderly patients, Lyder concluded that the Braden Scale was predictive for black elders but not for Hispanic elders.

Are clinicians missing early-stage pressure sores?

"The findings were pretty much unexpected," says Lyder. "I don’t think we know enough as to why they turned out that way." Lyder is requesting grant money from the NIH to further investigate factors that increase the risk of pressure ulcers in Black and Hispanic people.

In the larger study, 32% of the subjects developed stage I or II pressure sores, which is a much higher incidence than the average reported in acute-care settings, says Lyder. "My theory is that nurses and other health care professionals are not trained to assess color changes in dark skin, so they dismiss an [early-stage pressure sore] until it reaches stage II," Lyder says. "Some studies show that darker people have more severe ulcers for that reason."

In the study report, Lyder wrote that "[The Braden Scale] has not been tested with adequate numbers of black and/or Latino Hispanic elders. Moreover, no studies could be found that evaluated predictive physiological variables (e.g., serum albumin, total protein, hemoglobin, hematocrit, etc.) in either of these ethnic minority populations."1

The Braden Scale includes six categories that measure on a scale of one to four the degree to which a patient is limited or impaired. A score of "1" means "completely limited," and a score of four means "no impairment." The Braden Scale considers the following variables:

• how well the patient can respond to pressure-related discomfort;

• how much the skin is exposed to moisture;

• how active the patient is;

• how well the patient can change and control body position;

• the patient’s usual eating pattern;

• friction and shear.


1. Lyder CH, Chang Yu, Stevenson D, et al. Validating the Braden Scale for the prediction of pressure ulcer risks in blacks and Latino/Hispanic elders: A pilot study. Ostomy Wound Mgmt 1998; 44, 3A(Suppl):42S-49S.