Pressure injuries and skin tears are serious issues and “an ounce of prevention, is worth a pound of cure, as the expression goes.”
At Silver Healthcare Center, we take great pride in our ongoing commitment to be pro-active and vigilant in all areas of our clinical care.
Braden Scale for Predicting Pressure Ulcer Risk
This tool was developed in 1987 by Barbara Braden and Nancy Bergstrom. The purpose of the scale is to help health professionals, especially nurses, assess a patient’s risk of developing a pressure ulcer.
Many nurses use this special scoring system to evaluate a patient’s risk of developing a pressure ulcer. It consists of six categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score can range from 6 to 23 with a lower score indicating a higher risk. The level of risk indicates the intervention strategies that should be used.
At risk (Braden score 15 – 18) preventive interventions:
- Turn the patient on a regular schedule.
- Help the patient be as active as possible.
- Protect the patient’s heels.
- Use pressure-redistribution surfaces.
- Manage moisture, nutrition, friction, and shear.
- Advance to a higher level of risk if other major risk factors are present.
Moderate risk (Braden score 13 – 14) preventive interventions:
- Use same protocol as for ‘at risk’ patients.
- Position patient at 30° lateral incline using foam wedges.
High risk (Braden score 10 – 12) preventive interventions:
- Use same protocol as for ‘moderate risk’ patients.
- In addition to turning the patient on a regular schedule, make small shifts in their position.
Very high risk (Braden score = 9) preventive interventions:
- Use same protocol as for ‘high risk’ patients.
- Add a pressure-redistribution surface for patients with severe pain or with additional risk factors.
It is very important to make sure patients who are at risk of pressure ulcers are receiving proper care. Best use of the Braden Scale tool depends on the nurse’s focus and attention on which Braden sub-categories are driving the overall patient risk level. For instance, two patients can have an identical overall Braden score, but one patient is at risk because of poor nutrition while the other patient is at risk because he/she has been confined to the bed and unable to walk. Both will require completely different preventive interventions to reduce risk.
Key factors for consideration and adherence, are as follows:
- Positioning off at-risk areas
- Keeping skin clean and dry
- Refraining from vigorously massaging or rubbing areas at risk of pressure injury as friction can cause tissue damage and deterioration
- Maintaining or restoring continence levels
- Reducing excessive exposure to moisture for a specific area
- Keeping the patient hydrated and the skin moisturized with emollients