Pressure Ulcers: The Braden Scale

Introduction The Braden Scale is a tool that is used to measure patients at risk for developing pressure ulcers. A pressure ulcer is an injury to the skin over a bony prominence on the body. Pressure ulcers are staged depending on the severity of the injured tissue. A registered nurse administers the Braden Scale in a hospital setting or long-term care facility. The Braden Scale is administered by assessing the patient’s risk for developing pressure ulcers depending on the scores from the specific subscales. The Braden Scale is typically administered for one to two minutes. This measuring tool has six subscales that are used to determine specific factors that contribute to the increased risk for developing pressure ulcers. The six subscales
This guideline specifically targets pressure ulcer prevention. In: Evidence-based geriatric nursing protocols for best practice. The guideline was developed on May 30, 2003 and revised in 2012. The first recommendation for pressure ulcer prevention is to do a complete skin assessment on admission of the patient. With this inspect the skin for changes in color, and palpate for temperature changes and edema. Also ask the patient if he or she is experiencing pain over a bony prominence. If the patient has a catheter, oxygen, ventilator or other medical device, check the skin under the device. It is important for nurses to reassess patients when conditions change, or every 24 to 48 hours on a general unit, and every 12 hours on an ICU unit. The guideline for pressure ulcer prevention also includes using the Braden Scale as a standardized tool to assess risk for developing a pressure ulcer. When assessing the skin, it is recommended that a comparison be done with the tissue over the bony prominence and the surrounding tissue. If the tissue over the bony prominence is discolored, warm or cool to the touch, boggy or stiff, then further assessment and monitoring of the area is needed. To prevent skin breakdown do not massage over a bony prominence. For example, the sacrum, clean the skin at times of incontinence, and use proper lifting techniques when transferring a patient. Nutrition is also essential in reducing the risk for pressure ulcers. It is recommended for the patient to have adequate hydration status and a well balanced diet. To conclude, assess the skin for early signs of pressure ulcers and if a pressure ulcer is suspected monitor and heal the area of