NUR 684 Module 4 Evidence Paper Example

What the Evidence Supports About Risk Scores and Repositioning in Pressure Injury Prevention

[Student Name]

Southern New Hampshire University

NUR 684: Clinical Nurse Leader Capstone

Module Four Evidence Paper

[Instructor Name]

[Date]

What the Evidence Supports About Risk Scores and Repositioning in Pressure Injury Prevention

Two routines anchor pressure injury prevention on most hospital units: nurses score each patient's risk with the Braden scale, and they turn at-risk patients every two hours. Clearwater General's orthopedic floor writes both into policy, and both appear in the proposed heel bundle. Before the project builds on them, the clinical nurse leader needs to know how strong their evidence is. This paper examines the development of the Braden scale, a Cochrane review of whether risk tools improve outcomes and a Cochrane review of repositioning, and then explains how the findings shape the bundle.

How the Braden Scale Was Built

Bergstrom et al. (1987) set out to create a tool that nurses could use quickly to identify patients likely to develop pressure injuries. They based it on a model in which injuries result from the intensity and duration of pressure combined with the tissue's tolerance for it. The scale rates six areas, including the patient's ability to feel and respond to discomfort, how damp the skin stays, how active and mobile the patient is, how well they eat and how much the skin is dragged or sheared, and adds them into a total from 6 to 23, where lower totals mean higher risk. In prospective testing on hospital units, the scale predicted which patients developed injuries with reasonable accuracy, and the authors reported good agreement between trained raters.

The scale was designed to predict, not to prevent. A good predictor tells nurses whom to worry about; it does not say what to do or guarantee that acting on the score changes outcomes. That distinction matters for the next source.

Do Risk Tools Reduce Injuries?

Moore and Patton (2019) searched for randomized trials comparing structured risk assessment with clinical judgment or with other tools, looking at whether using a tool actually reduced pressure injuries. They found very few eligible trials. The evidence that did exist was of low certainty, and the reviewers concluded that it is uncertain whether using a structured tool lowers the incidence or severity of injuries compared with nurses' judgment alone.

This does not mean the Braden scale is useless. It means that scoring by itself protects no one; what matters is whether a score reliably triggers the right prevention. A unit can document Braden scores at every shift and still have high injury rates if a score of 15 does not lead to heel offloading. That is exactly what the unit's audit showed: 82% of patients had a timely score, but only three of eleven at-risk patients had offloading devices in place.

How Often and How Should Patients Be Turned?

Gillespie et al. (2014) reviewed randomized trials of repositioning for preventing pressure injuries in adults, including studies comparing different turning intervals and different positions, such as a 30-degree tilt versus lying fully on one side. The trials were few, often small and at risk of bias, and they did not show clear differences between the schedules or positions compared. The reviewers concluded that the evidence could not establish the best frequency or position, even though repositioning is a cornerstone of prevention.

The absence of evidence for a particular interval is not evidence that repositioning is unnecessary. The physiology of pressure and tissue damage is well understood, and no one proposes leaving immobile patients in one position. Instead, the review suggests that a rigid every-two-hours rule is a convention rather than a proven optimum and that repositioning should be tailored to the patient's risk, skin response and support surface.

What This Means for Heel Injuries

Neither review focused on heels, and the Braden scale does not capture some risks that matter most for hip fracture patients: hours on a stretcher before surgery, anesthesia, a leg that cannot move and pain that discourages shifting. Heels bear concentrated pressure over a small area with little tissue padding, and turning a patient from side to side does not necessarily lift the heels off the mattress. For this group, direct offloading of the heel, keeping it free of the mattress entirely, addresses the mechanism more directly than a turning schedule.

Translating the Evidence into Bundle Rules

The CNL's role is to turn uncertain evidence into clear, defensible practice. Three rules follow. First, every hip fracture patient is treated as at risk from arrival, regardless of Braden score, because the known risk factors of this group are not fully captured by the scale. Second, a Braden score of 18 or below in any other patient triggers specific actions, heel offloading, a repositioning plan and a nutrition referral, so the score leads somewhere. Third, repositioning is individualized: at least every two hours as a floor, more often if skin shows redness that does not fade and always paired with heel offloading, since turning alone may not relieve the heel.

Table 1 summarizes the evidence and the rule each source supports.

Table 1. Evidence and Resulting Bundle Rules

Note. Rules combine evidence with known physiology and the unit's audit data.

Communicating Uncertainty to Staff

Staff may ask why the unit is changing a two-hour rule they have followed for years, or why a Braden score no longer decides everything. The CNL will explain at huddles that the rules are not being loosened but made more precise: scores now trigger actions, turning is tailored and heels get direct protection. Being candid about what research does and does not show tends to build trust, and it models evidence-based practice for newer nurses.

Conclusion

The Braden scale predicts risk but does not by itself prevent harm, and the best frequency and position for repositioning remain unknown. For hip fracture patients, the evidence and physiology together support treating everyone as at risk, making scores trigger action and offloading heels directly. The next milestone reviews the evidence on whole prevention bundles.

References

Bergstrom, N., Braden, B. J., Laguzza, A., & Holman, V. (1987). The Braden Scale for predicting pressure sore risk. Nursing Research, 36(4), 205-210. https://doi.org/10.1097/00006199-198707000-00002

Gillespie, B. M., Chaboyer, W. P., McInnes, E., Kent, B., Whitty, J. A., & Thalib, L. (2014). Repositioning for pressure ulcer prevention in adults. Cochrane Database of Systematic Reviews, 2014(4), Article CD009958. https://doi.org/10.1002/14651858.CD009958.pub2

Moore, Z. E., & Patton, D. (2019). Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews, 2019(1), Article CD006471. https://doi.org/10.1002/14651858.CD006471.pub4