Understanding the Braden Scale: Focus on Moisture (Part 2)

By Holly Hovan MSN, APRN, CWOCN-AP

A series analyzing the use of the Braden Scale for Predicting Pressure Sore Risk® in the long-term care setting. For part 1, click here.

When nurses hear the term moisture, they usually almost always think of urinary or fecal incontinence, or both. There are actually several other reasons why a patient could be moist. Continued moisture breaks down the skin, especially when the pH of the aggravating agent is lower (urine, stomach contents—think fistula, stool). When there is too much moisture in contact with our skin for too long, we become vulnerable to this moisture, and our skin breaks down. Increased moisture places a patient at risk for a pressure injury as the skin is already in a fragile state.

Sources of Moisture

Moisture isn't always caused by urinary or fecal incontinence; some of the other sources of moisture are listed below:

• Diaphoresis
• Fistula leakage
• Weepy legs from venous insufficiency/edema/heart failure
• Moisture around peristomal area with tracheostomy patients
• Body habitus/folds, especially in warmer weather
• Spilling the urinal when using it in bed (men)
• A highly exudative wound (wound drainage is moisture)
• Leaky ostomy pouch
• Leakage from around indwelling Foley catheter secondary to bladder spasms or other reason

Braden Scale: Categories of Moisture

The subcategories under moisture are:

• Constantly moist
• Very moist
• Occasionally moist
• Rarely moist

Moisture is mainly measured by how frequently the bed sheets are changed when utilizing the Braden Scale for Predicting Pressure Sore Risk®; more specific definitions are outlined in the attached sheet.

Take away points for assessing moisture when using the Braden Scale include: consider heavily draining wounds, weepy legs, tracheostomy patients, obese patients with large abdominal pannus, difficulty maneuvering urinal resulting in spillage, and additional topics as discussed above.

Interventions for Moisture

Taking the Braden Scale one step further, if you've identified that your patient is a risk for this subcategory, moisture, you need to put interventions into place. What are some interventions that could help with moisture management in addition to linen changes? Think about the causes for moisture and how you can reverse or fix them. Providing an intervention to the deficiencies within the Braden Scale subcategories will decrease the risk of pressure injury related to that specific cause.

I hope you will continue to join me monthly as I break down the subcategories of the Braden Scale and discuss interventions along with key points for nursing staff education.

Note: For anyone who wishes to utilize the Braden Scale in their health care facility, you must request permission to do so. Please visit www.bradenscale.com and complete the Permission Request form.

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.