Braden Scale for Predicting Pressure Ulcer Risk

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

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

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

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

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

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

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

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

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

External links

• Braden Scale Official Website
• Braden Scale Instruction Sheet
• Braden Scale Assessment Form