Braden Scale for Predicting Pressure Ulcer Risk: Difference between revisions

Latest revision as of 11:49, 1 April 2025

The Braden Scale for Predicting Pressure Ulcer Risk is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstrom. It is used to assess the risk of patients developing pressure ulcers (also known as bedsores or decubitus ulcers) by evaluating several factors that contribute to the likelihood of skin breakdown.

Assessment using the Braden Scale[edit]

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

Sensory Perception[edit]

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]

Excessive and continuous skin moisture can compromise the integrity of the skin by causing the tissue to become macerated and therefore more vulnerable to epidermal erosion. This category assesses the degree of moisture the skin is exposed to, which can come from incontinence, perspiration, or wound drainage.

Activity[edit]

This category evaluates a patient's level of physical activity. Very little or no activity can lead to muscle atrophy and breakdown of tissue due to reduced blood flow. The more active a patient is, the less likely they are to develop a pressure ulcer.

Mobility[edit]

This category assesses a patient's ability to independently adjust their body position. This includes the physical ability to move, as well as the willingness to move. The less mobile a patient is, the higher the risk for pressure ulcer development.

Nutrition[edit]

The assessment of a client's nutritional status looks at their dietary intake patterns. Poor nutrition, such as inadequate protein intake or caloric restriction, can increase the risk of skin breakdown and delay healing. Malnourished individuals are more vulnerable to developing pressure ulcers.

Friction and Shear[edit]

This category assesses the amount of assistance a patient needs to move and the degree of sliding they experience on beds or chairs. Friction and shear occur when the skin is pulled in one direction while the underlying tissues are moving in the opposite direction, which can lead to skin and tissue breakdown. Moisture exacerbates this risk, making the skin more prone to injury.

Scoring with the Braden Scale[edit]

Each category is rated on a scale of 1 to 4, excluding the 'friction and shear' category, which is rated on a scale of 1 to 3. This results in a total possible score of 23 points, with higher scores indicating lower risk of developing a pressure ulcer. Conversely, a lower score indicates a higher risk.

The Braden Scale assessment score scale is as follows:

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

The total score can help healthcare providers make decisions about the level of care and interventions needed to prevent or treat pressure ulcers.

External links[edit]

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-The '''Braden Scale for Predicting Pressure Ulcer Risk''', is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstrom.<ref>
+The '''Braden Scale for Predicting Pressure Ulcer Risk''' is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstrom. It is used to assess the risk of patients developing pressure ulcers (also known as bedsores or decubitus ulcers) by evaluating several factors that contribute to the likelihood of skin breakdown.
-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.</ref> The purpose of the scale is to help health professionals, especially nurses, assess a patient's risk of developing a [[pressure ulcer]].<ref>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/</ref>
-==Assessment using the Braden Scale==
+== Assessment using the Braden Scale ==
-The Braden scale assesses a patient's risk of developing a pressure ulcer by examining six criteria:<ref>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> {{webarchive |url=https://web.archive.org/web/20110712225753/http://www.hsag.com/App_Resources/Documents/CA_HSAG_LS3_Risk_Cassell.pdf |date=July 12, 2011 }}.</ref>
+The Braden scale assesses a patient's risk of developing a pressure ulcer by examining six criteria:
-===Sensory perception===
+=== Sensory Perception ===
 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===
+=== Moisture ===
-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 [[epidermis (skin)|epidermal]] erosion. So this category assesses the degree of moisture the skin is exposed to.
+Excessive and continuous skin moisture can compromise the integrity of the skin by causing the tissue to become macerated and therefore more vulnerable to [[epidermis (skin)|epidermal]] erosion. This category assesses the degree of moisture the skin is exposed to, which can come from incontinence, perspiration, or wound drainage.
-===Activity===
+=== Activity ===
-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.<ref>{{cite web|url=http://cwx.prenhall.com/bookbind/pubbooks/martinidemo/chapter10/medialib/CH10/html/ch10_5_3.html |title=Archived copy |accessdate=2011-02-27 |deadurl=yes |archiveurl=https://web.archive.org/web/20110715112134/http://cwx.prenhall.com/bookbind/pubbooks/martinidemo/chapter10/medialib/CH10/html/ch10_5_3.html |archivedate=2011-07-15 |df= }}</ref>
+This category evaluates a patient's level of physical activity. Very little or no activity can lead to muscle atrophy and breakdown of tissue due to reduced blood flow. The more active a patient is, the less likely they are to develop a pressure ulcer.
-===Mobility===
+=== Mobility ===
-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.
+This category assesses a patient's ability to independently adjust their body position. This includes the physical ability to move, as well as the willingness to move. The less mobile a patient is, the higher the risk for pressure ulcer development.
-===Nutrition===
+=== Nutrition ===
-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.
+The assessment of a client's nutritional status looks at their dietary intake patterns. Poor nutrition, such as inadequate protein intake or caloric restriction, can increase the risk of skin breakdown and delay healing. Malnourished individuals are more vulnerable to developing pressure ulcers.
-===Friction and Shear===
+=== Friction and Shear ===
-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. <ref>"Bedsores (pressure sores)." Mayo Clinic, 30 Mar 2009. Web. 25 Feb 2011. http://www.mayoclinic.com/health/bedsores/DS00570/DSECTION=causes.</ref>
+This category assesses the amount of assistance a patient needs to move and the degree of sliding they experience on beds or chairs. Friction and shear occur when the skin is pulled in one direction while the underlying tissues are moving in the opposite direction, which can lead to skin and tissue breakdown. Moisture exacerbates this risk, making the skin more prone to injury.
-==Scoring with the Braden Scale==
+== Scoring with the Braden Scale ==
-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.<ref>{{cite journal |vauthors=Jiricka MK, Ryan P, Carvalho MA, Bukvich J |title=Pressure ulcer risk factors in an ICU population |journal=Am. J. Crit. Care |volume=4 |issue=5 |pages=361–7 |year=1995 |pmid=7489039 |doi= |url=}}</ref>
-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==
+Each category is rated on a scale of 1 to 4, excluding the 'friction and shear' category, which is rated on a scale of 1 to 3. This results in a total possible score of 23 points, with higher scores indicating lower risk of developing a pressure ulcer. Conversely, a lower score indicates a higher risk.
+The Braden Scale assessment score scale is as follows:
+* '''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
+The total score can help healthcare providers make decisions about the level of care and interventions needed to prevent or treat pressure ulcers.
+== See also ==
 * [[Pressure ulcer]]
 * [[Wound healing]]
 * [[Waterlow score]]
+* [[Nursing care plan]]
+* [[Incontinence]]
+* [[Chronic wounds]]
-==References==
+== External links ==
-{{Reflist}}
+* [http://www.bradenscale.com/index.htm Braden Scale Official Website]
+* [https://www.healthcare.uiowa.edu/igec/tools/pressureulcers/bradenScale.pdf Braden Scale Instruction Sheet]
-==External links==
+* [http://www.in.gov/isdh/files/Braden_Scale.pdf Braden Scale Assessment Form]
-*[http://www.bradenscale.com/index.htm Braden Scale Official Website]
-*[https://www.healthcare.uiowa.edu/igec/tools/pressureulcers/bradenScale.pdf Braden Scale Instruction sheet]
-*[http://www.in.gov/isdh/files/Braden_Scale.pdf Braden Scale Assessment form]
 [[Category:Nursing]]
 [[Category:Medical scales]]
-{{dictionary-stub1}}
+[[Category:Patient care]]
-{{No image}}
+[[Category:Wound care]]
+[[Category:Pressure ulcer prevention]]