Braden Scale for Predicting Pressure Ulcer Risk

From WikiMD's Wellness Encyclopedia

The Braden Scale for Predicting Pressure Ulcer Risk, is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstrom.[1] The purpose of the scale is to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer.[2]

Assessment using the Braden Scale[edit | edit source]

The Braden scale assesses a patient's risk of developing a pressure ulcer by examining six criteria:[3]

Sensory perception[edit | edit source]

This parameter measures a patient's ability to detect and respond to discomfort or pain that is related to pressure on parts of their body. The ability to sense pain itself plays into this category, as does the level of consciousness of a patient and therefore their ability to cognitively react to pressure-related discomfort.

Moisture[edit | edit source]

Excessive and continuous skin moisture can pose a risk to compromise the integrity of the skin by causing the skin tissue to become macerated and therefore be at risk for epidermal erosion. So this category assesses the degree of moisture the skin is exposed to.

Activity[edit | edit source]

This category looks at a patient's level of physical activity since very little or no activity can encourage atrophy of muscles and breakdown of tissue.[4]

Mobility[edit | edit source]

This category looks at the capability of a patient to adjust their body position independently. This assesses the physical competency to move and can involve the clients willingness to move.

Nutrition[edit | edit source]

The assessment of a client's nutritional status looks at their normal patterns of daily nutrition. Eating only portions of meals or having imbalanced nutrition can indicate a high risk in this category.

Friction and Shear[edit | edit source]

Friction and shear looks at the amount of assistance a client needs to move and the degree of sliding on beds or chairs that they experience. This category is assessed because the sliding motion can cause shear which means the skin and bone are moving in opposite directions causing breakdown of cell membranes and capillaries. Moisture enhances the susceptibility of friction. [5]

Scoring with the Braden Scale[edit | edit source]

Each category is rated on a scale of 1 to 4, excluding the 'friction and shear' category which is rated on a 1-3 scale. This combines for a possible total of 23 points, with a higher score meaning a lower risk of developing a pressure ulcer and vice versa. A score of 23 means there is no risk for developing a pressure ulcer while the lowest possible score of 6 points represents the severest risk for developing a pressure ulcer.[6] The Braden Scale assessment score scale:

  • Very High Risk: Total Score 9 or less
  • High Risk: Total Score 10-12
  • Moderate Risk: Total Score 13-14
  • Mild Risk: Total Score 15-18
  • No Risk: Total Score 19-23

See also[edit | edit source]

References[edit | edit source]

  1. ↑ Kozier, Barbara, Glenora Erb, Shirlee Snyder, and Audrey Berman. Fundamentals of Nursing: Concepts, Process, and Practice. 8th ed. Upper Saddle Riveer, NJ: Pearson Education, 2008. 905-907. Print.
  2. ↑ U.S. National Library of Medicine, Initials. (2009, May 20). 2009aa braden scale source information. Retrieved from https://www.nlm.nih.gov/research/umls/sourcereleasedocs/2009AA/LNC_BRADEN/
  3. ↑ Cassell, Charisse. "Pressure Ulcer Risk Assessment: The Braden Scale for Prediction Pressure Sore Risk." Health Services Advisory Group of California, Inc., n.d. Web. 25 Feb 2011. <http://www.hsag.com/App_Resources/Documents/CA_HSAG_LS3_Risk_Cassell.pdf> Archived July 12, 2011, at the Wayback Machine.
  4. ↑ "Archived copy". Archived from the original on 2011-07-15. Retrieved 2011-02-27. {{cite web}}: Unknown parameter |deadurl= ignored (help)CS1 maint: archived copy as title (link)
  5. ↑ "Bedsores (pressure sores)." Mayo Clinic, 30 Mar 2009. Web. 25 Feb 2011. http://www.mayoclinic.com/health/bedsores/DS00570/DSECTION=causes.
  6. ↑

External links[edit | edit source]

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Contributors: Prab R. Tumpati, MD