By Margaret Heale, RN, MSc, CWOCN
In our point, click, fill-in-the -blanks world of ever increasing wound care algorithms and MOs, I have an ax to grind (straight into my so-called smart phone if I had the courage).
By Holly Hovan MSN, APRN, CWOCN-AP
The Braden Scale for Predicting Pressure Sore Risk® category of activity focuses on how much (or how little) the resident can move independently. A resident can score from 1 to 4 in this category, 1 being bedfast and 4 being no real limitations. It is important to keep in mind that residents who are chairfast or bedfast are almost always at risk for skin breakdown.
The Braden Scale activity categories are broken down by:
Remember, when calculating the Braden Score, the higher the number, the lower the risk. So, if someone is 19 or above, there is no risk for pressure injury development based on our evidence-based tool.
With that being said, when looking at activity, it is important to break down the Braden Scale categories and look at details. If residents are walking with a prosthesis, they’re at risk for friction or shear (another category of the Braden Scale), even though their activity level may be acceptable. If they have a wound on their foot and are non–weight bearing, they’re going to be spending more time in bed or chair, putting them at a higher risk. If they’re a fall risk and need assistance with ambulation, they may not be walking as much as someone who needs no assistance. If they’re short of breath with exertion and can complete only transfers or maybe a couple of steps, then they would be at risk in this category. Many residents who are hospitalized are not functioning at their normal capacity in terms of mobility; they’re weaker, have pain, have shortness of breath, are not feeling 100%, etc. A resident’s level of activity may change depending on the shift, but it is important to look at the overall picture of the resident, not just that the resident is sleeping in bed on night shift.
In summary, activity is a small part of a larger scale that contributes to the big picture of: is this person at risk for developing a hospital-acquired pressure injury? If so, what interventions can I put into place to decrease this risk? Some things to think about are consulting physical or occupational therapy after consulting with the provider, if appropriate, evaluating for appropriate seating and sleeping surfaces, performing turns every two hours, weight shifting when up to the chair, toileting, hourly rounding, and encouraging mobility and independence as much as possible.
As we look at the Braden Scale score in its entirety, it is always important to look at the big picture and ascertain why the resident is at risk. That way, appropriate interventions can be put into place to prevent pressure injuries.
About the Author
Holly is a board certified gerontological nurse and advanced practice wound, ostomy, and continence nurse coordinator at The Department of Veterans Affairs Medical Center in Cleveland, Ohio. She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately six years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention. She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation. She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible. She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.