Original Research: Use of the Braden Scale at a school for learners with special needs
Use of the Braden Scale for Predicting Pressure Sore Risk© at a school for learners with special needs
Swart CP, BSc OT, DHT, IIWCC Junior Occupational Therapist, Muriel Brand School Correspondence to: Ronél Swart, e-mail:
[email protected] Keywords: occupational therapist, enrolled nurse, spinal cord injuries, Braden Scale, pressure ulcer risk assessment, paediatric pressure ulcers Wound Healing Southern Africa 2011;4(2):74-79
Peer reviewed. (Submitted: 2011-02-08, Accepted: 2011-09-14). © Medpharm
Introduction
of the necessary equipment to measure tissue perfusion further discouraged its use in this study.4,6
Children with physical disabilities face numerous daily challenges. They might suffer ridicule and rejection from peers based on their
Four hundred and fifty learners, ranging in age from three to 20 years,
appearance, or the way in which they talk and walk. They also face
and with learning and/or physical disabilities, attend the Muriel Brand
the possible occurrence of co-morbid medical conditions as a result
School. As such, their needs are addressed by a comprehensive
of poor relay of information, or lack of assessment. This would
paramedical team consisting of OTs, physiotherapists (PTs), ENs,
further impact their compromised quality of life. In 2010, as an
psychologists and speech therapists. An incontinence clinic caters
occupational therapist (OT) at a special needs school, I encountered
to 22 incontinent learners, teaching self-catheterisation and bowel
two wheelchair-bound spinal cord injury (SCI) learners who had
routine to improve personal hygiene and maintain skin integrity
been suffering from pressure-related ulcers for more than a year.
through moisture control.8-10
This was due to ignorance about the pressure ulcer (PU) formation
PU development issues in wheelchair-bound SCI learners, including
mechanism.1 Attempts to address this led to use of the Braden Scale
their assessment, seating and positioning, can be addressed by
for Predicting Pressure Sore Risk© (the Braden Scale) to predict and
OTs, PTs and ENs.1 Sensory or motor function may be lost following
prevent PU development in six SCI learners, after which its efficacy was assessed.1,2
SCI. This can affect the ability to sense pain or discomfort, exercise
The Braden Scale (Table I) is an assessment tool that was developed
changes in movement to relieve pressure on pressure points.1,8-11
bladder control, evacuate the bowels and execute frequent small
by Braden and Bergstrom in 1983.2,3 Although initially designed
Wheelchair-bound cerebral palsied (CP) learners also have increased
for adult patient use, Bolton found that in a comparison with the
risk for PU formation arising from friction during muscle spasms, or
Waterlow Scale and the Norton Scale, it scored the highest in
prolonged pressure caused by neurological deficits, which result in
terms of validity and reliability.4 Pancorbo-Hidalgo et al described
an inability to move out of pressure-inducing positions.12
the Braden Scale to be the best predictor in PU risk estimation.4,5 Bolton et al also reported it to be effective for use in patients from
In this study, the risk of PU development in SCI learners had to be
five years upwards, of mixed gender, and who were either bed- or
assessed. A comprehensive prevention protocol for the learners
wheelchair-bound within the rehabilitation setting.4,6 The Braden
and caregivers was documented in order to decrease the identified
Scale is less complex, possibly less time consuming, and clear and
risks.1
concise in comparison to other scales, including the Waterlow Scale and the Norton Scale.1,2,7 It also correlates well with the American
Method
Occupational Therapy Association’s (AOTA) practice framework,
Study design
discussed by Braden and Blanchard.1,2 An OT’s understanding of
This was a prospective cohort study to determine the effectiveness
the Braden Scale’s assessment criteria is imperative, and it is a tool that the enrolled nurses (EN) would be comfortable using. As a result
of the Braden Scale1.1,2,13
of these considerations, the researcher decided to use the Braden
Table II lists the study’s inclusion and exclusion criteria.
Scale.2 Use of the Braden-Q Scale, a paediatric version of the Braden Scale, is intended for hospital-bound children and has several sub-scales, including the measurement of tissue perfusion.4,6 Lack
Wound Healing Southern Africa
74
2011 Volume 4 No 2
Original Research: Use of the Braden Scale at a school for learners with special needs
Table I: The Braden Scale for Predicting Pressure Sore Risk in Home Care©2 SENSORY PERCEPTION ability to respond meaningfully to pressure-related discomfort
1. Completely limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation. OR Limited ability to feel pain over most of body.
2. Very limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness. OR Has a sensory impairment which limits the ability to feel pain or discomfort over half of the body.
3. Slightly limited Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR Has some sensory impairment which limits ability to feel pain or discomfort in one or two extremities.
MOISTURE degree to which skin is exposed to moisture
1. Constantly moist 2. Often Moist Skin is kept moist almost Skin is often, but not constantly by perspiration, always moist. Liner must urine, etc. Dampness be changed as often as 3 is detected every time times in 24 hours. patient is moved or turned.
3. Occasionally Moist 4. Rarely Moist Skin is occasionally moist, Skin is usually dry; Linen requiring an extra linen only requires changing at change approximately routine intervals. once a day.
ACTIVITY degree of physical activity.
1. Bedfast Confined to bed.
2. Chairfast Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.
3. Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of day in bed or chair.
4. Walks Frequently Walks outside bedroom twice a day and inside room at least once every two hours during waking hours.
MOBILITY ability to change and control body position
1. Completely Immobile Does not make even slight changes in body or extremity position without assistance.
2. Very Limited Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.
3. Slightly Limited Makes frequent though slight changes in body or extremity position independently.
4. No Limitation Makes major and frequent changes in position without assistance.
NUTRITION usual food intake pattern
1. Very Poor Never eats a complete meal. Rarely eats more than ½ of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR Is NPO and/or maintained on clear liquids or IV’s for more than 5 days.
1. Very Poor Never eats a complete meal. Rarely eats more than ½ of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR Is NPO and/or maintained on clear liquids or IV’s for more than 5 days.
3. Adequate 4. Excellent Eats over half of most Eats most of every meal. meals. Eats a total of 4 Never refuses a meal. servings of protein (meat, Usually eats a total of dairy products per day. 4 or more servings of Occasionally will refuse meat and dairy products. a meal, but will usually Occasionally eats between take a supplement when meals. Does not require offered supplementation. OR Is on a tube feeding or TPN regimen which probably meets most of nutritional needs.
FRICTION & SHEAR
1. Problem 2. Potential Problem Requires moderate to Moves feebly or requires maximum assistance in minimum assistance. moving. Complete lifting During a move skin without sliding against probably slides to some sheets is impossible. extent against sheets, Frequently slides down chair, restraints or other in bed or chair, requiring devices. Maintains frequent repositioning relatively good position with maximum assistance. in chair or bed most of Spasticity, contractures or the time but occasionally agitation leads to almost slides down. constant friction.
3. No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.
Total score
© Copyright. Barbara Braden and Nancy Bergstrom, 1988. Reprinted with permission. All Rights Reserved.
Wound Healing Southern Africa
4. No impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel, or voice pain or discomfort.
75
2011 Volume 4 No 2
Original Research: Use of the Braden Scale at a school for learners with special needs
Table III: Gender, age and diagnoses of study participants (n = 6)
Table II: Inclusion and exclusion criteria Inclusion criteria:
Participant Gender
• Mixed-gender SCI learners
Girl C
Female
10 years, Paraplegia with neurogenic bladder. 7 months
Girl L
Female
12 years, Spina bifida with concomitant 8 months hydrocephalus (ventriculoperitoneal shunt inserted). Neurogenic bladder (kidney failure).
Girl N
Female
12 years, Paraplegia secondary to a motor vehicle 9 months accident. Spinal tuberculosis.
Girl F
Male
10 years, Spina bifida with ventriculoperitoneal 0 months shunt
Boy G
Male
11 years, Spina bifida. 8 months
Boy I
Male
15 years, Congenital spinal deformity with failure 2 months of formation of L1 and L2. Congenital dislocated left hip. Incontinent.
• Age range: five to 19 years • Attending a school for learners with special needs • Identified through a chart review • Informed consent obtained from learners’ parents. Exclusion criteria: • Learners with pre-existing pressure ulcers or other ulcers • Presence of neurological defects, e.g. cerebral palsy and cerebrovascular accident.
The cohort study design enabled treatment of all the participants, avoiding ethical issues in other study designs, for instance, in a randomised controlled trial.14 During the course of this study, the design changed into that of an observational descriptive study.1 All participants were assessed equally, comparisons were not made between them, and everybody received a prevention protocol based on their risk factors.2,14 Bailey calls this a quasi-experimental, follow-up, time-series design, in which the experimental group also becomes the control group.15 One pre-test precedes and several post-tests follow, and the intervention is provided.15 During the study, two prevention protocols were provided, and adapted as participants’ risk factors changed.13 It can also be seen as a single-group, timeseries design, with pre- and post-testing of each intervention.15 Expressed diagrammatically, it is as follows: O1 X O2 X O3 O4 (O = assessment, X = intervention ).15
Age
Diagnoses
Participant sample Table III shows the gender, age and diagnoses of the study participants. Data collection One OT and one EN familiarised themselves with the Braden Scale, and decided on a method to follow in the scoring of the assessment areas.1,2 They performed screening of the learners together, to ensure consistency in follow-up screenings. During the screening process, queries that arose between the OT and EN were discussed and clarified, with immediate implementation of newfound knowledge. Participants were questioned in their vernacular regarding their nutrition, activity and mobility. Where necessary, an interpreter was provided for second language speakers. Parents or caregivers were contacted to obtain any information not provided by the learners themselves.
Study objectives The first study objective was an increase of two points per participant in total score achieved, with reassessment of the risk of PU development using the Braden Scale within eight weeks of the first assessment, following implementation of prevention strategies appropriate to each individual.1,2,13 The second study objective was none-to-minimal development of new PU, following the risk assessment and prevention implementation. 1,2,11,13
Sensory perception testing was performed in private. The participants’ skin was exposed, except for areas covered by underwear, to enable observation of overall skin condition, without execution of a standard skin assessment.16 Clean, unused toothpicks were pressed down against the participants’ skin for a second, eliciting a “painful” experience by indenting, but not breaking, the skin on an unaffected area (mostly the forearm). The dorsal and volar aspect of the upper limbs, torso (medial to the spine and more lateral towards sides of the body), and lower limbs were then tested. If participants responded “yes” or flinched, it was recorded as a painful stimulus, but if the stimulus was innocuous, participants were asked to remain quiet.2
Planning and implementation Permission was obtained from the principal at the school where the research project was conducted. Letters of information and consent were sent to the parents of 22 learners who satisfied the project’s inclusion criteria. Tear-off return slips were included to provide consent for the learners’ inclusion in this project, eight slips being returned before the cut-off date. One potential participant was eliminated due to pre-existing PU not noted on his chart. Because of lack of access to school records, after data collection occurred it emerged that the youngest participant was younger than five years of age, and her results were excluded from this study because the unmodified Braden Scale is not appropriate for learners below this age.2,6
Friction and shear occurring within the wheelchair, and on other surfaces, were evaluated.1 Participants had to move from their wheelchairs to wide, built-in benches (slightly higher than the wheelchair seat) and back to their wheelchairs.1 Observations were made on the type of movement causing skin friction and shear (a shuffling or sliding action) made by their buttocks between surfaces, and whether or not they lifted themselves completely using their arms and hands, and pivoted when moving to the adjacent surface.1,11
Wound Healing Southern Africa
76
2011 Volume 4 No 2
Original Research: Use of the Braden Scale at a school for learners with special needs
Four screenings were performed using the Braden Scale.2 Due to
Lacking random assignment of participants to two groups, no
labour action causing two participants to be stranded at home, these
conclusions could be drawn on whether or not the implementation
two were only screened three times.17 On two occasions, written
of a prevention protocol made a difference in the final obtained
prevention protocols were provided to the participants, and modified
scores.14 This transformed the study into a quasi-experimental,
according to each participant’s risk rating.1,13 Zinc-and-castor oil
follow-up, time-series design, as opposed to the prospective cohort
ointment was given to incontinent participants to act as a barrier
study that was initially planned.14,15 The mean age of the participants
cream to promote moisture control and maintain skin integrity.
was 12 years, 2 months. Poor generalisability of the study findings
11,13
exist because of the small sample size of learners between the ages
Results and discussion
of 5 and 19.14
Following collection of each participant’s data, the scores under each
Data collection was performed over a three-month period, using
sub-section were graphically depicted (Figures 1-7).2 Open spaces in
a standard screening tool with clear, concise definitions that
the bar graph illustrate a participant’s absence from school on the
simplified the process for evaluators so that they could determine
assessment date.
each participant’s risk level.1,2 The small sample group was easily
Participants with neurogenic bladders had a greater chance of
managed, and proper follow-up of each participant’s risk factors was
occasional urinary incontinence and moisture causing lower scores
conducted. Prevention protocols were provided to reduce overall risk
in the moisture sub-scale.2,18 The participant’s understanding
of PU formation, as well as learner and caregiver education, given
and level of sensory perception also played a great role in the
through contact sessions and telecommunications.1,12,13,22 Humphry
risk of their developing PU, observed in Girl N’s (Figure 3) second
and Case-Smith state the importance of regular telephonic and
assessment, during which a stage 2 PU developed on her lower
other contact with caregivers, to discuss information which they
back along the waistband of her trousers.11,19 Her adherence to the
can understand and to which they can relate.23 Better still, they
prevention protocol provided could have been compromised by poor
recommend calling a meeting with the caregiver to obtain in-depth
understanding of the written protocol, and a disinclination to take
information relating to the child’s treatment, or to discuss possible
responsibility for her own care.20 The PU resulted from absence of
interventions to be carried out at home by caregivers and the
pain sensation below the thorax level, increased level of moisture
children.23 Consequently, it would have been even more beneficial
(no diapers), and the elastic of her trousers pressing against the skin
for the study investigators to meet with the participants’ caregivers
around her waist.1,11,12
to explain the various aspects of the prevention protocols in greater
Some participants became more motivated to show an improvement
detail.
in follow-up PU risk assessments. This was possibly due to an
A diagrammatic representation of the dermatomes, using colour
improved understanding, communicated to them by the evaluators,
codes to depict different types of sensation, would also have been
that their decisions would impact on their risk levels. This is similar
helpful.1,24 Even though the Braden Scale has a high level of validity
to what Armstrong et al reported, that staff members communicated
for age groups ranging from five years upwards in various settings,
various ways to prevent PU, and consequently improved adherence.20
this study found that it was not specific enough in evaluating the
According to Braden and Blanchard, the cut-off score for the risk of
needs of learners in different age groups as it is an adult PU risk
PU formation is below 19 points.1 Five out of six participants recorded
assessment tool primarily.1,4 When assessing a learner, the approach
initial scores varying between 11 (high risk) and 18 (mild risk), while
should be holistic. This tool uses only one of many assessment
the sixth participant’s (Girl L’s) score of 20 points posed the least
approaches and clinical observations.25 The Braden Scale2 correlates
risk of PU development.1,13 Following implementation of customised
well with the AOTA’s practice framework, discussed by Braden and
prevention protocols and the final assessment, all participants
Blanchard.1,2 However, following a literature review, it was found
showed improvement.13 However, Girl L’s score remained at
that the Glamorgan Scale was more specific to paediatric patients’
20 points. Girl N had a reduction, followed by an increase in her scores,
needs, and its use is possibly more appropriate for the type of study
and four other participants (Girl L, Boy F, Boy G, and Boy I) recorded
undertaken.22
a score that was above the cut-off score for risk of developing PU after protocol implementation.1,13 Their mobility improved, while a
This quantitative study measured the risk of PU formation using the
greater internal motivation enhanced their physical activity. This
Braden Scale over a three-month period.2 Study objectives were
correlates with reasons provided by Majnemer for motivation to
reached, with participants’ scores increasing by two points overall.
change, namely gaining personal enjoyment from physical activity
In summary, the total reduction in PU risk means that the Braden
or a reward (increased scores), which in turn warrants an increase
Scale and its accompanying prevention protocol promoted an
in their physical activity. Girl C and Girl N reduced their risk of PU
increased awareness among the study participants regarding factors
formation,1,13 and the overall improvement in total scores varied
potentially leading to PU formation, and provided education on how
between 2 and 7 points (Figure 7).
to overcome these risks.1,2,13
21
Wound Healing Southern Africa
77
2011 Volume 4 No 2
Original Research: Use of the Braden Scale at a school for learners with special needs
Diagrammatic representation of individual scores Girl C
Boy F
Figure 1: Braden Scale assessment scores for Girl C on four occasions
Figure 4: Braden Scale assessment scores for Boy F on four occasions
Girl L
Boy G
Figure 5: Braden Scale assessment scores for Boy G on four occasions
Figure 2 : Braden Scale assessment scores for Girl L on four occasions
Girl N
Boy I
Figure 3: Braden Scale assessment scores for Girl N on three occasions
Figure 6: Braden Scale assessment scores for Boy I on three occasions
Combined group scores
Conclusion The Braden Scale is an easy, fast, clear and concise PU risk assessment tool, and can be used by both nurses and OTs collaboratively.1,2,4 However, it should be used in conjunction with other assessments and clinical observations in order to acquire a holistic appreciation of a learner.1,23,24 Through the use of this scale and its accompanying prevention protocol, a reduction in level of risk was achieved for five out of the six participants. 2,13 This study was conducted as an elective for the International Interprofessional Wound Care course. Figure 7: Combined total scores pertaining to Braden Scale assessment of six participants
Wound Healing Southern Africa
78
2011 Volume 4 No 2
Original Research: Use of the Braden Scale at a school for learners with special needs
Declaration of interest for all authors
11. Weir D. Pressure ulcers, assessment, classification, and management. In:Krasner DL, Rodeheaver GT, Sibbald RG, editors. Chronic wound care: a clinical source book
There was no conflict of interest.
for healthcare professionals. Wayne, Pa: Health Management Publications, 2007; p. 575-581.
Ethics approval
12. Barnes S. The use of pressure ulcer risk assessment tool for learners. Nursing Times. 2004;100(14):56-58 [homepage on the Internet] c2010. Available from:
No ethics approval was required. Permission was obtained from the
http://www.nursingtimes.net/nursing-practice-clinical-research/the-use-of-a-
principal of the school where the research project was conducted.
pressure-ulcer-risk-assessment-tool-for-Learners/204474.article 13. Braden B. (2001) Protocols by level of risk [homepage on the Internet]. c2010.
Funding
Available from: http://www.bradenscale.com/images/protocols_by_level_of_risk. pdf
The research was funded by the researcher.
14. Woodbury MG. Research 101: developing critical appraisal skills. Wound Care
Acknowledgements
15. Bailey DM. Research for the health professional: a practical guide. Philadelphia: F A
Canada. 2004;2(2):32-38 Davis Company, 1997; p. 60-77.
Gratitude is expressed to Daleen Morgenrood (enrolled nurse),
16. Pressure sore data collection questionnaire skin assessment tool (Nurse II)
Muriel Brand School, for assisting in collecting data from the study
[homepage on the Internet]. c2010. Available from: http://www.bradenscale.com/
participants, and to Barbara Braden (PhD, RN, FAAN) and Nancy
images/skinassessmenttool.pdf
Bergstrom (PhD, RN, FAA) for permission to use the Braden Scale for
17. Maclennan B. Nationwide strike set to intensify. Mail and Guardian [newspaper
Predicting Pressure Sore Risk©.
online].
2010
Aug
19.
c2010.
Available
from:
http://www.mg.co.za/
article/2010-08-19 -nationwide-strike-set-to-intensify
References
18. Neurogenic bladder. The Free Dictionary [homepage on the Internet]. c2010. Available from: http://medical-dictionary.thefreedictionary.com/neurogenic+bladder
1. Braden BJ, Blanchard S. Risk assessment in pressure ulcer prevention. In: Krasner DL, Rodeheaver GT, Sibbald RG, editors. Chronic wound care: a clinical source book for healthcare professionals. Wayne, Pa: Health Management Publications, p. 593-608.
19. Butler CT. Pediatric skin care: guidelines for assessment, prevention, and treatment. Pediatr Nurs. 2006;32(5):443-50 [homepage on the Internet]. c2010. Available from: http://ovidsp.tx.ovid.com.myaccess.library.utoronto.ca (via www.ptolemy.ca)
2. Braden B, Bergstrom N. Braden Scale for predicting pressure sore risk in home care [homepage on the Internet]. c2010. Available from: http://www.bradenscale.com/ images/bschome.pdf
20. Armstrong DG, Ayello EA, Leask Capitulo K, et al. Opportunities to improve pressure
3. Prevention Plus. About us {homepage on the Internet]. c2011. Available from: http:// bradenscale.com/about%20us.htm
Wounds. 2008;20(9):A14-A26 [homepage on the Internet]. c2011. Available from:
4. Bolton L. Which pressure ulcer risk assessment scales are valid for use in the clinical setting? J Wound Ostomy Continence Nurs. 2007;24(4):368-381.
21. Majnemer A. Importance of motivation to children’s participation: a motivation to
ulcer prevention and treatment: implications of the CMS inpatient hospital care present on admission (POA) indicators/hospital-acquired conditions (HAC) policy. http://www.medscape.com/viewarticle/581767 change. Physical & Occupational Therapy In Pediatrics. 2011;31(1):1-3 [homepage
5. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, Alvarez-Nieto C. Risk assessment scales for pressure ulcer prevention: a systematic review [homepage on the Internet]. c2011. Available from: http://onlinelibrary.wiley.com.myaccess. library.utoronto.ca/doi/10.1111/j.1365-2648.2006.03794.x/pdf. J Adv. Nurs. 2006;54(1):94-110.
on the Internet]. c2011. Available from: http://journals1.scholarsportal.info. myaccess.library.utoronto.ca/tmp/9540583451066403215.pdf 22. Wu SSH, Ahn CMD, MS Emmons KR, Salcido R. Pressure ulcers in pediatric patients with spinal cord injury: a review of assessment, prevention, and topical
6. LINKS guideline: Braden Scale, modified Braden Q Scale, neonatal/infant Braden Q Scale [homepage on the Internet]. c2010. Available from: http://lane.stanford.edu/ portals/cvicu/HCP_Skin_Integrity_Tab_4/Braden_Scale_for_Children.pdf
management. Advances in Skin & Wound Care: The Journal for Prevention and Healing. 2009;22(6):273-284 [homepage on the Internet]. c2010. Available from: http://www.nursingcenter.com/library/JouENalArticle.asp?Article_ID=863785
7. Waterlow J. Waterlow pressure ulcer prevention/treatment policy [homepage on the Internet]. c2010. Available from: www.judy-waterlow.co.uk on 13/05/2010.
23. Humphry R, Case-Smith J. Working with families. In: Case-Smith J, editor. Occupational therapy for children. New York: Elsevier Mosby, 2005; p.117-159.
8. Atkins MS. Spinal cord injury. In: Trombly CA, Radomski MV, editors. Occupational therapy for physical dysfunction, New York: Lippincott Williams & Wilkins, 2002; p. 965-1000.
24. Apparelyzed – spinal cord injury peer support. Dermatome chart/Dermatome map [homepage on the Internet]. c2010. Available from: http://www.apparelyzed.com/
9. Shepherd J. Activities of daily living and adaptations for independent living. In: CaseSmith J, editor. Occupational therapy for children. New York: Elsevier Mosby, 2005; p. 521-570.
dermatome.html 25. Willock J, Harris C, Harrison J, Poole C. Identifying the characteristics of learners with pressure ulcers. Nurs Times. 2005; 101(11):15-21, 40-3 [homepage on the
10. Newman DK, Preston AM, Salazar S. Moisture control, urinary and fecal incontinence, and perineal skin management. In: Krasner DL, Rodeheaver GT, Sibbald RG, editors. Chronic wound care: a clinical source book for healthcare professionals. Wayne, Pa: Health Management Publications, 2007; p. 609-627.
Wound Healing Southern Africa
Internet]. c2010. Available from: http://www.nursingtimes.net/nursing-practiceclinical-research/identifying-the-characteristics-of-Learners-with-pressureulcers/203951.article
79
2011 Volume 4 No 2