Braden Scale vs. Waterlow Scale for Assessment

Topic: Nursing
Words: 718 Pages: 2

One of the common problems amongst the geriatric, bed-bound, immobile, unalert, and patients with limited mobility is the development of pressure ulcers. They occur when some areas of the skin do not receive an adequate amount of blood flow due to constant pressure, and as a result, the tissue is damaged. Pressure ulcers occur significantly often in skilled nursing/rehab facilities due to a lack of knowledge, training, and continuing education. As well as poor communication between staff in different departments within the facility, such as nursing staff, physicians, physical therapist, unlicensed assistant personnel, and the dietary department. There should be constant dialogue and communication between these departments to provide the best care to the patient and exude knowledge and implementation of interdisciplinary care. Many times, simple indicators of the initial development are overlooked due to a lack of knowledge, such as recognizing non-blanching of skin, assessing bony prominence areas, malnutrition, dehydration, and predisposed diseases.

The paper aims to compare two assessment scales to predict pressure ulcers – the Braden Scale and Waterlow Scale – to prove that the Braden Scale is a better assessment tool. The Braden Scale is one of the most well-known and often-used scales for determining the likelihood of developing pressure ulcers. It has been frequently utilized in acute clinical settings as well as long-term nursing care settings, with validity and reliability having been established.

The Waterlow scale is another tool frequently used in risk assessment of developing pressure ulcers. However, the validity of the Waterlow scale is under question. According to Charalambous et al. (2018), the Waterlow scale is characterized by high sensitivity (82.4%) and low specificity (27.4%), which are considered acceptable (p. 143). However, to measure predictive validity, the patient should not be given preventive measures. In reality, if the patient is assessed to be at high risk, they are given preventive measures. Due to this, the predictive validity of the Waterlow scale is evaluated as inadequate (Charalambous et al., 2018). Moreover, the reliability of the Waterlow scale is another nuisance. When the risk of pressure ulcers among 40 elderly people was assessed using the Waterlow scale, the agreement of two assessors accounted for only 25%, which is considered a low result (Charalambous et al., 2018, p. 143). Therefore, the use of the Waterlow scale is inefficient due to its reliability and validity.

Similar results are presented by Šáteková et al. (2015). The Waterlow scale has high sensitivity (85.71%) and negative predictive value (92.85%) in the current investigation but low specificity (30.23%) and positive predictive value (16.66%) (Šáteková et al., 2015, 288). As a result, preventive interventions might be started in patients who do not actually require them, increasing the expense of both prevention and nursing labor. Furthermore, the ROC curve’s area under the curve was small (0.579). This is not enough value. In order to confirm or disprove the Waterlow Scale’s predictive validity, further testing is required.

There is conflicting information regarding the Braden Scale’s sensitivity and validity. The Braden Scale has been extensively researched recently and is frequently utilized in clinical settings. According to a meta-analysis by Wei et al. (2020), the Braden Scale has a low specificity (0.42), a moderate sensitivity (0.80), and a moderate predictive value (AUC: 0.7686 ± 0.0478) for predicting the risk of PUs in long-term care. The mean age of the studied patients was above 50 years. Despite low sensitivity, the research by Huang et al. (2021) estimated the cut-off values of 16 and 18, and so recommended to be used in clinical practice (p. 2201). Therefore, the effectiveness of the Braden scale is also a subject of further studies.

However, when comparing the Waterlow scale and the Braden scale, the accuracy of the Braden scale is found to be higher. According to Valiee et al. (2022), the specificity of the Braden scale was 34.5%, while the specificity of the Waterlow scale accounted for only 28.5%, which indicates that the predictive value of the Braden scale is higher when assessing patients in an intensive care unit (p. 164). Zhang et al. (2021) suggest that the low performance of the Waterlow scale is because the Waterlow scale is more suitable for intraoperative settings than assessing patients in the intensive care unit (p. 7). Hence, the Braden Scale is more effective in predicting pressure ulcers in ICU patients.


Charalambous, C., Koulori, A., Vasilopoulos, A., & Roupa, Z. (2018). Evaluation of the Validity and Reliability of the Waterlow Pressure Ulcer Risk Assessment Scale. Medical Archives, 72(2), 141.

Huang, C., Ma, Y., Wang, C., Jiang, M., Yuet Foon, L., Lv, L., & Han, L. (2021). Predictive validity of the Braden scale for pressure injury risk assessment in adults: A systematic review and meta‐analysis. Nursing Open, 8(5), 2194–2207.

Šáteková, L., Žiaková, K., & Zeleníková, R. (2015). Predictive validity of the Braden scale, Norton scale and Waterlow scale in Slovak Republic. Cent Eur J Nurs Midw, 6(3), 283-290.

Valiee, S., Nemati, S. M., Hossaini, M., Kashefi, H., & Mohammadi, H. (2022). Comparing the accuracy of the Braden and the Waterlow scales for pressure ulcer risk assessment in the intensive care unit. Nurs Midwifery Stud, 11, 160-5.

Wei, M., Wu, L., Chen, Y., Fu, Q., Chen, W., & Yang, D. (2020). Meta‐analysis: Predictive validity of Braden for pressure ulcers in critical care. Nursing in Critical Care.

Zhang, Y., Zhuang, Y., Shen, J., Chen, X., Wen, Q., Jiang, Q., & Lao, Y. (2021). Value of pressure injury assessment scales for patients in the intensive care unit: Systematic review and diagnostic test accuracy meta-analysis. Intensive and Critical Care Nursing, 64.

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