Skill Page - Braden Scale

06 FEB 2015

Prevention of pressure ulcer & Braden Scale Assessment

Ms Soumya Thomas, Staff Nurse

Pressure ulcer
A pressure ulcer is a lesion that develops on the skin and underlying tissues usually over boney area due to unrelieved pressure.

Common sites

1. Sacrum
2. Coccyx
3. Heels or Hips
4. Elbows
5. Knees
6. Ankles

Braden Scale
Definition: It is the tool to assess the patient’s risk for developing pressure ulcer.

Braden Scale : crieteria
Sensory perception-4
Moisture - 4
Activity -4
Mobility -4
Nutrition -4
Friction and Shear -3
Total Score -23

Braden scale : Sensory Perception
Completely Limited
Very Limited
Slightly Limited
No Impairment

Braden Scale: Moisture
Constantly Moist
Very moist
Occasionally Moist
Rarely Moist

Braden scale : Activity
Bed fast
Chair fast
Walks occasionally
Walks frequently

Braden scale : Mobility
Completely immobile
Very limited
Slightly limited
No limitation

Braden scale : Nutrition
Very poor
Probably inadequate
Adequate
Excellent

Braden scale : Friction and shear
Problem – requires maximum assistance.
Potential problem
No apparent problem

Braden scale : scores
Very high risk: total score 9 or less
High risk : 10-12
Moderate risk : 13-14
Mild risk : 15-18
No risk : 19-23

Stages of pressure ulcer-stage 1
Intact skin with redness of localized area usually over a bony prominence.

Stages of pressure ulcer-stage II
Superficial breakdown, partial thickness loss of dermis open ulcer with a red pink wound without slough.

Stages of pressure ulcer-stage III
full thickness tissue loss. Subcutaneous fat may be visible but bone,tendon or muscle are not exposed. Slough may be present

Stages of pressure ulcer-stage IV
Full thickness tissue loss with exposed bone,tendon or muscle. Slough or eschar may be present on some parts of the wound
 

Stages of pressure ulcer
Full thickness tissue loss in Which the base of the ulcer Is covered by slough or eschar In the wound.

PREVENTIVE BUNDLES Of PRESSURE ULCER
RISK ASSESSMENT
Assess all at-risk patients at the time of admission to health care and reassess at least every 24 hourly
Document risk assessment
Perform a head to toe skin assessment at least daily, especially checking pressure points such as sacrum, ischium , trochanters , heels ,elbow and back of the head
Use a mild cleansing agent, avoid hot water and excessive rubbing. Use lotion after bath
Use moisturizer for dry skin
Avoid massage over bony prominences

CHANGING POSITION
Making regular and frequent changes position is one of the most effective ways of preventing pressure ulcers
Change position 2nd hourly
Wheelchair users will need to change their position at least once every two hours
Provide wrinkle free bed
Provide alpha bed
Use pillow to keep bony prominences, such as knee and ankles
Provide back care

NUTRITION
Provide healthy, balanced diet that contain adequate amount of protein and a good verity of vitamins and minerals can help to prevent skin damage
 
Nurses role
Identifying at risk groups
Repositioning
Skin inspection
Pressure redistributing devices
Seating
Educating and training
Documentation