The Braden Scale is a widely used assessment tool that enables healthcare professionals to evaluate the risk of pressure ulcer development in individuals. Developed by Dr. Barbara Braden and Nancy Bergstrom, this scale considers various physical and environmental factors that can influence an individual’s risk of developing pressure ulcers. By assessing these factors, its users can identify patients who are at risk and provide them with the appropriate preventive strategies.
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What is the Braden Scale?
The Braden Scale is a tool nurses use to assess patients’ risk of pressure ulcer development. An American nurse, Nancy Braden, developed it in 1987, and is widely used worldwide. It evaluates six areas, including sensory perception, skin moisture, activity level, friction & shear forces, nutrition, and overall mobility, to determine the likelihood of developing pressure ulcers.
The scale assigns a score from 6-23, with higher scores indicating lower risk of developing pressure ulcers and vice versa. By evaluating these six areas, the Braden Scale helps healthcare professionals identify high-risk skin breakdown patients and develop appropriate interventions to reduce that risk. Additionally, it can help nurses determine when to initiate preventive measures such as turning and repositioning patients more frequently.
How Does it Help with Pressure Ulcer Prevention?
The Braden Scale can help nurses develop individualized care plans for each patient. It also enables healthcare professionals to identify which patients may benefit from more intensive interventions such as specialized mattresses or cushions, nutritional changes, and medications. The scale serves as a basis for pressure ulcer prevention and helps clinicians evaluate how effectively their preventive measures have reduced the risk of skin breakdown.
Overall, the Braden Scale is a valuable tool for helping healthcare professionals assess and monitor patient’s risk of pressure ulcer development and take preventive measures to reduce this risk. With its help, nurses can ensure their patients are safe from skin breakdown and receive the best care.
What are the Components of the Braden Scale Assessment & Tracking ?
The Braden Scale evaluates six areas to determine the risk of pressure ulcer development. These include:
- Sensory Perception – This refers to patients’ awareness of their environment and ability to sense pain or discomfort.
- Skin Moisture – This assesses how much moisture is present in patients’ skin, which may put them at risk for pressure ulcers.
- Activity Level – This assesses the patient’s physical activity level and ability to move independently.
- Friction & Shear Forces – This evaluates how much friction and shear forces are present in a patient’s environment, which can increase their risk of pressure ulcer development.
- Nutrition – This assesses a patient’s nutritional status and ability to get the necessary nutrients.
- Mobility – This measures the patient’s overall mobility, including their ability to sit in bed or turn independently.
By assessing these six areas, nurses can determine a patient’s risk of pressure ulcer development and take the necessary preventive measures.
The Braden Scale is a valuable tool for helping nurses evaluate and monitor patients’ risk of pressure ulcer development.
Scoring of Braden Scale
The total score ranges from 1 to 23, with higher scores indicating a lower risk of pressure ulcers.
19-23: No risk of pressure ulcers
15-18: Low risk of pressure ulcers
13-14: Moderate risk of pressure ulcers
10-12: High risk of pressure ulcers
6-9: Very high risk of pressure ulcers
The following six areas of assessment determine the total calculation of scores:
- Sensory perception – Score range: 1-4
- Skin moisture – Score range: 1-4
- Activity level – Score range: 1-4
- Friction & shear forces – Score range: 1-3
- Nutrition – Score range: 1-4
- Overall mobility – Score range: 1-4.
With the help of the Braden Scale, nurses can ensure that their patients receive appropriate interventions to reduce their risk of pressure ulcers and receive the best possible care. It serves as a basis for effective prevention and helps clinicians evaluate how successful their preventive measures have been in reducing the risk of skin breakdown.
What are the Benefits of the Braden Scale?
• Helps nurses identify patients at high risk for developing pressure ulcers
• Enables healthcare professionals to develop individualized plans of care
• Can help determine which patients will benefit from more intensive interventions
• Aids in the evaluation of how effective preventive measures have been in reducing risk
• Serves as a basis for pressure ulcer prevention and helps clinicians monitor and evaluate risk
• Helps ensure patients receive the best possible care and are safe from skin breakdown.
What are the Limitations of the Braden Scale?
• Requires an experienced clinician to interpret results accurately
• Does not take into account other factors that may increase risk, such as age, gender, or comorbidities
• Can be time-consuming to administer and score compared to other scales
• Scoring can be subjective depending on the individual clinician’s interpretation
• Does not provide information on the type of intervention needed to manage risk.
What Should I Do If My Score Is High?
If your score on the Braden Scale is high, you have a higher chance of developing pressure ulcers. To reduce this risk, it is important to take specific preventive measures. These may include:
• Frequent repositioning or turning while in bed
• Specialized mattress and/or cushion support systems
• Appropriate nutrition and hydration
• Careful skin assessments to identify any risk areas early on
• Use of friction-reducing techniques such as pressure redistribution surfaces
• Proper use of assistive devices such as walkers or wheelchairs.
Additionally, it is vital to stay in close communication with healthcare professionals who can monitor your risk and provide necessary interventions if needed.
Bradon Scale Assessment
- Assess patient’s ability to move independently. Look for physical limitations or impairments such as paralysis, muscle weakness, limited range of motion, or joint pain.
- Ask about the nature and frequency of skin breakdowns. Look for areas of redness that may indicate friction or shear forces during movement.
- Examine the patient’s skin for moisture, dryness, or temperature.
- Ask questions related to nutritional intake and hydration level. Take note of any difficulty with swallowing or reduced appetite.
- Note any sensory awareness impairment such as changes in vision, hearing ability, smell, taste, etc.
- Assess the patient’s activity level and environment. Look for potential safety risks such as loose cords or rugs.
- Determine the patient’s cognition level and any communication difficulties. Ask if they can make decisions, follow instructions, or understand verbal commands.
- Observe the patient’s social interaction and emotional state. Look for signs of depression, fear, aggression, or confusion.
- Assess the patient’s ability to access support such as family and friends. Ask about their relationship with caregivers or healthcare providers.
- Document your assessment results and make any necessary changes to the patient’s care plan accordingly.
This comprehensive evaluation should be conducted on an ongoing basis in order to effectively manage the risk of skin breakdown and other complications associated with immobility. Healthcare professionals can use the Braden Scale to provide objective data for making clinical decisions and providing appropriate interventions.
What Are the Alternatives to the Braden Scale?
The Braden Scale is widely used, but other scales are available to assess pressure ulcer risk. These include the Waterlow Scale, Norton Scale, and Braden-Kerluke Scale. Each scale has its own set of criteria for evaluating risk, and it is up to the clinician to decide which one is most appropriate for a particular patient.
What does a Braden Scale score of 16 mean?
A score of 16 on the Braden Scale indicates that an individual is at low risk for developing pressure ulcers. This means preventive measures can be taken to reduce the risk further, such as proper positioning and regular skin assessments.
What does the Braden Q scale score mean?
The Braden-Q scale is a modified version of the original Braden Scale that includes a seventh category, “Social Support”. This score provides additional information about the support system in place for an individual and can help healthcare professionals develop more effective interventions to reduce pressure ulcer risk.
The Braden Scale is a vital tool for healthcare professionals to assess and track patients’ risk of pressure ulcer development. It can help clinicians identify which patients are at higher risk, develop individualized care plans, and take preventive measures to reduce this risk. While other scales are available to assess pressure ulcer risk, the Braden Scale remains reliable for ensuring that patients receive the best possible care and are safe from skin breakdown.
Mrs. Marie Brown has been a registered nurse for over 25 years. She began her nursing career at a Level I Trauma Center in downtown Chicago, Illinois. There she worked in the Emergency Department and on the Surgical Intensive Care Unit. After several years, she moved to the Midwest and continued her nursing career in a critical care setting. For the last 10 years of her nursing career, Mrs. Brown worked as a flight nurse with an air ambulance service. During this time, she cared for patients throughout the United States.