Assessing Pressure Ulcer Risk and Ensuring Appropriate Prevention MeasuresSandy Kingsley RN BSN MSN WCCJuly 7 2014ObjectivesIdentify the 6 subscales comprising the Braden ScoreUnderstand how to comple ID: 898113
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1 Braden Scale Assessing Pressure Ulcer
Braden Scale Assessing Pressure Ulcer Risk and Ensuring Appropriate Prevention Measures Sandy Kingsley, RN, BSN, MSN , WCC July 7, 2014 Objectives ï Identify the 6 subscales comprising the Braden Score ï Understand how to complete the Braden Scale accurately ï Identify preventati
2 ve measures and interventions appropria
ve measures and interventions appropriate to each category of risk ï Understand the relationship between the driver of risk and the appropriate interventions for the patient related to that driver What is the Braden Scale? ï Scoring system ï Evaluates patientâs risk of developing a pres
3 sure ulcer ï Braden Scale â mos
sure ulcer ï Braden Scale â most preferred tool ï Six categories assessed Why Assess Pressure Ulcer Risk? ï Significant problem in older hospitalized adults ï PU and treatment negatively affect every dimension of patientâs life ï Expensive to treat Categories ï Sensory
4 perception ï Moisture ï Activit
perception ï Moisture ï Activity ï Mobility ï Nutrition ï Friction/shear Sensory Perception ï 1. Completely Limited ï Unresponsive ï Limited ability to feel pain over MOST of body ï 2. Very Limited ï Painful stimuli ï Cannot communicate discomfort ï Se
5 nsory impairment over HALF of body ï
nsory impairment over HALF of body ï 3. Slightly Limited ï Verbal commands ï Cannot always communicate discomfort ï Sensory Impairment â 1 - 2 extremities ï 4. No Impairment ï Verbal commands ï No sensory deficit Moisture ï 1. Constantly Moist ï Perspiration, uri
6 ne, etc. ï Always ï 2. Very Mo
ne, etc. ï Always ï 2. Very Moist ï Often but not always ï Linen changed at least once per shift ï 3. Occasionally Moist ï Extra linen change Q day ï Rarely Moist ï Usually dry Activity ï 1. Bedfast ï Never OOB ï 2. Chairfast ï Ambulation severely limi
7 ted to non - existent ï Cannot bear
ted to non - existent ï Cannot bear own weight â assisted to chair ï 3. Walks Occasionally ï Short distances daily with or without assistance ï Majority of time in bed or chair ï 4. Walks Frequently ï Outside room 2 x per day ï Inside room q 2 hours during waking hours M
8 obility ï 1. Completely Immobile ï
obility ï 1. Completely Immobile ï Makes no changes in body or extremity position ï 2. Very Limited ï Occasional slight changes in position ï Unable to make frequent/significant changes independently ï 3. Slightly Limited ï Frequent slight changes independently ï 4. No Lim
9 itation ï Major and frequent changes
itation ï Major and frequent changes without assistance Nutrition ï 1. Very Poor ï Never eats complete meal/rarely � 1/3, 2 or proteins/day ï NPO, clear liquids, IVs � 5 days ï 2. Probably Inadequate ï Rarely eats complete meal, approx. 1/2, 3 proteins ï Occasio
10 nally takes dietary supplement ï Rec
nally takes dietary supplement ï Receives less than optimum liquid diet or tube feeding ï 3. Adequate ï Eats over 1/2 of most meals, 4 proteins ï Usually takes a supplement ï Tube feeding or TPN probably meets nutritional needs ï 4. Excellent ï Eats most of meals, never refuses
11 , 4 or more proteins ï Occasionally
, 4 or more proteins ï Occasionally eats between meals ï Does not require supplements Friction and Shear ï 1. Problem ï Moderate to maximum assistance in moving ï Frequently slides down in bed or chair ï Spasticity. contractures or agitation leads to almost constant friction ï
12 2. Potential Problem ï Moves feeb
2. Potential Problem ï Moves feebly, requires minimum assistance ï Skin probably slides against sheets, etc. ï Relatively good position in chair or bed with occasional sliding ï 3. No Apparent Problem ï Moves in bed and chair independently ï Sufficient muscle strength to lift u
13 p completely during move ï Good posi
p completely during move ï Good position in bed or chair Scoring ï 19 - 23 â not at risk ï 15 - 18 â preventative interventions ï 13 - 14 â moderate risk ï 10 - 12 â high risk ï 6 - 9 â very high risk Braden Score 15 - 18 Preventative Intervention
14 s (At Risk) ï Regular turning schedu
s (At Risk) ï Regular turning schedule ï Enable as much activity as possible ï Protect the heels ï Use pressure redistribution surfaces ï Manage moisture, friction and shear ï Advance to a higher level of risk if other major risk factors are present Braden S core 13 - 14 Preven
15 tative Interventions (Moderate Risk)
tative Interventions (Moderate Risk) ï Use the same protocol as for âat riskâ patients ï Position patient at 30 degree lateral incline using foam wedges Braden Scale 10 - 12 Preventative Interventions (High Risk) ï Follow the same protocol as for moderate risk ï In addition to reg
16 ular turning schedule ï Make small s
ular turning schedule ï Make small shifts in their position frequently Braden Scale = 9 or Preventative Interventions (Very High Risk) ï Use same protocol as for âhigh riskâ patients ï Add a pressure redistribution surface for patients with severe pain or with additional risk factors
17 . Best Use of Braden Scale ï De
. Best Use of Braden Scale ï Dependent on nurses focus and attention on which Braden sub - categories are driving the overall risk level. ï Understanding of all the definitions and scoring rules. Mr. P; A Case Study ï Status post fractured left hip with total hip replacement, lives
18 alone ï Incision dry, intact, no sig
alone ï Incision dry, intact, no signs of infection and edges well approximated ï Skin assessment on admission and in 24 hours ï Special attention to heels and sacrum ï No reddened areas noted ï Cognitively alert; Pain 8/10 ï Sensory perception subscale Case Study Contâd ï
19 Perspiring heavily; no evidence of i
Perspiring heavily; no evidence of incontinence or wound drainage ï Moisture subscale ï Out of bed with assistance and wheeled walker, PT 5 x per week, toe touch weight bearing left leg ï Activity subscale ï Mobility subscale ï Friction and shear subscale Case Study Contâd
20 ï Eating habits at home ï Ban
ï Eating habits at home ï Banana, coffee for breakfast ï Cereal for lunch ï Canned soup and cookies for dinner ï Normal BMI (23.5) ï States he has little appetite and often eats only if he feels like it ï Does not take a dietary supplement Braden Score Total ï Sensory
21 perception = 4 ï Moisture = 3 ï
perception = 4 ï Moisture = 3 ï Activity = 3 ï Mobility = 2 ï Nutrition = 1 ï Friction and shear = 2 TOTAL = 15 preventative interventions Interventions Based on Risk Assessed ï Heels offloaded ï Turning and repositioning regularly ï Encourage as much activity as po
22 ssible ï Pressure redistribution sur
ssible ï Pressure redistribution surfaces for bed and chair ï Manage moisture, friction and shear ï Specific turning sheet ï Daily inspection of skin with attention to heels and sacru m Putting the Pieces Together ï Use interview questions AND physical assessment to complete the s
23 cale. ï Include the family and/or c
cale. ï Include the family and/or caregiver if unable to answer questions appropriately ï If in doubt, always give the lower score which will increase the level of risk ï Determine the subscale that is driving the highest risk ï Put interventions in place to address the highest risk s
24 ubscale as a priority as well as those n
ubscale as a priority as well as those needed to address the level of risk from the other subscales ï If other risk factors are identified that are not addressed within the subscales, implement appropriate strategies to address them. 2 nd Case Study ï Mrs. C. has had dementia for many year
25 s and is non - verbal and does not follo
s and is non - verbal and does not follow any commands ï Incontinent of bowel and bladder multiple times throughout the day with no indication of awareness ï No longer able to bear weight. OOB with mechanical lift and 2 assistants. ï Weight 95 lbs. Height 5â10 â; unable to feed herself
26 ï Skin assessment â stage 1 sac
ï Skin assessment â stage 1 sacrum, bilateral heels with unstageable areas due to dry, black eschar Score/Interventions Score ï Sensory/perception â 2 ï Moisture â 2 ï Activity â 2 ï Mobility â 1 ï Nutrition â 1 ï Friction and shear â
27 1 ï Total â 9 â very high
1 ï Total â 9 â very high risk Interventions ï TAPS ï Incontinence care ï Weight shifting in chair ï Pressure redistribution mattress and cushion ï Heel offloading ï Dietary consult with dietary interventions /supplementation ï Turning/pull device Questi
28 ons References Wound Rounds, What i
ons References Wound Rounds, What is the Braden Scale? , https://www.woundrounds.com/wound - care - technologies/what - is - the - braden - scale/ , WWW May 19, 2014. Stotts , N.A., EdD , RN, FAAN, Gunningberg , L., PhD, RN. How to Try This: Predicting Pressure Ulcer Risk. American Journa
29 l of Nursing, Nov 2007, 107(11), pgs
l of Nursing, Nov 2007, 107(11), pgs 40 - 48. http://www.nursingcenter.con/Inc/cearticle?tid=751548 , WWW May 19, 2014. References ï Revis , D.R., MD. Pressure Ulcers and Wound Care. Medscape Reference Drugs, Diseases & Procedures. Updated March 12, 2014. http://emedicine.medscape.com