As we shifted from “turning Q 2 hours” for positioning our patients to “individualized positioning based on tissue tolerance,” many clinicians were unsure how best to establish a plan of care.
How do we determine the positioning frequency? What is the pressure injury risk for our patients? How can we quantify risk to drive plan of care for positioning?
The Braden Scale for Predicting Pressure Ulcer/Sore Risk is a great tool to assist with those questions.
What is the Braden Scale?
The Braden Scale quantifies pressure injury risk through an assessment sequence and calculating a numerical score to assign risk. Subsequent risk calculations can be determined at later dates to re-assess risk and determine positioning needs.
This process is also a great tool to drive plan of care and assist with defensible documentation to prevent litigation. However, despite this being a helpful tool, it should be used to support your clinical judgment and not replace it. Let’s take a deep dive into the Braden Scale assessment and scoring.
How to Use the Braden Scale
The Braden Scale utilizes the following six factors in its assessment sequence:
- Sensory perception — Assess the ability to respond meaningfully to pressure-related discomfort: There are four scores ranging from completely limited (1 point) to no impairment (4 points). Patients with a loss of protective sensation cannot determine when they need to move themselves to prevent a pressure injury. This also applies to critically ill patients lacking the alertness to sense the discomfort.
- Moisture — Assess the degree to which the skin is exposed to moisture: There are four scores ranging from constantly moist (1 point) to rarely moist (4 pts). Moisture can potentially macerate or denude the epidermis, leaving the skin layers at higher risk for injury.
- Activity — Assess the degree of physical mobility. There are four levels ranging from bedfast (1 point) to walks frequently (4 pts). It is also important to consider patients in transit. How long will the individual be in a chair to go to a physician appointment? Will dialysis or wound care be involved? Working across the continuum of care will avoid an “out of sight out of mind” risk factor.
- Mobility — Assess the ability to change and control body position. There are four potential points ranging from completely immobile (1 point) to no limitations (4 pts). This is possibly the biggest indicator of pressure injury risk. Patients unable to position themselves need assistance to modify this risk or avoidable injury can occur. (NPIAP 2019)
- Nutrition — Assess the usual food intake pattern. This includes scoring for NPO, IV, and TPN sources of nutrition. Scores range from very poor (1 point) to excellent (4 pts). Nutrition is one of the most overlooked and undervalued aspects of pressure injury risk.
- Friction and Shear — Assess the risk of friction and shear with moving the patient. Friction may cause partial thickness wounds, while shearing causes full thickness wounds with jagged wound margins, as well as potential undermining and tunneling.
Braden Scale scores ranging from 15-18 indicate mild risk, scores 13-14 determine a moderate risk, scores 10-12 equal high risk with scores <9 indicating a SEVERE risk.
Once the risk for pressure injury is determined, we can develop a plan of care for positioning. To determine the optimal turning frequency, clinicians need to look at all the risk factors and the support surface they will be using. Once they have determined the optimal frequency, they must verify its effectiveness by doing tissue tolerance assessments.
Reducing the risk of pressure injury development is challenging and varies from patient to patient. Establishing proper risk assessments that are comprehensive and employ tools like the Braden Scale can improve outcomes and reduce the incidence of facility-acquired pressure injuries.
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