Braden Scale

WoundSource Editors's picture
Risk Assessment Standardization

By the WoundSource Editors

The prevalence of pressure injuries among certain high-risk patient populations has made pressure injury risk assessment a standard of care. When utilized on a regular basis, standardized assessment tools, along with consistent documentation, increase accuracy of pressure injury risk assessment, subsequently improving patient outcomes. Conversely, inconsistent and non-standardized assessment and poor documentation can contribute to negative patient outcomes, denial of reimbursement, and possibly wound-related litigation.

Holly Hovan's picture
Braden Scale: Mobility

By Holly Hovan, MSN, RN-BC, APRN-CNS, CWOCN-AP

What is mobility? Typically, when we hear the word mobility, we think about our ability to move, with or without assistance. In a long-term care setting, we often hear the words, "mobility aids," which are typically pieces of medical equipment that are used to enhance mobility—wheelchairs, walkers, canes, power wheelchairs, crutches, and even guide dogs for those who are sight impaired. There are many intrinsic and extrinsic factors that impact one's mobility, which will be discussed in this blog.

Heidi Cross's picture
Risk Assessment

by Heidi H. Cross, MSN, RN, FNP-BC, CWON

When looking at medical charts from a legal perspective, one of the areas closely scrutinized is the risk assessment for skin breakdown and pressure ulcer development. Completing a risk assessment is considered a standard of care. Was the patient adequately assessed, and was this done in a timely fashion? Was it repeated at regular intervals, with a change in condition, or on readmission? Do scores seem appropriate for the patient's condition? Is there consistency among health practitioners? Were the results used to institute evidence-based and appropriate prevention and treatment measures and care plans? Or do the results seem to simply languish in the chart? What are the standards of care related to this?

Holly Hovan's picture
patient repositioning

By Holly Hovan MSN, APRN, CWOCN-AP

Friction and shear… what’s the difference and how do they cause pressure injuries? Are wounds caused by friction and shear classified as pressure injuries? What’s the easiest way to explain the differences between these critical components of the Braden Scale for Predicting Pressure Sore Risk® that are not always understood? How do I know if my patient is at risk?

Holly Hovan's picture
patient mobility and activity

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

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Holly Hovan's picture
enteral nutrition feeding

By Holly Hovan MSN, APRN, CWOCN-AP

A common misconception by nurses is sometimes predicting nutritional status based on a resident's weight. Weight is not always a good predictor of nutritional status. Nutritional status is determined by many factors and by looking at the big picture.

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Holly Hovan's picture
Moisture on Skin

By Holly Hovan MSN, APRN, CWOCN-AP

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.

Holly Hovan's picture
neuropathy testing for sensory perception (Braden Scale)

By Holly Hovan MSN, APRN, CWOCN-AP

As wound care professionals, the Braden Scale for Predicting Pressure Sore Risk® is near and dear to our hearts. With that in mind, our evidence-based tool needs to be used correctly in order to yield accurate results. Working with long-term care and geriatric populations opens up a world of multiple pre-existing comorbidities and risk factors that aren’t always explicitly written into the Braden Scale categories. Additionally, the frequency of the Braden Scale may also contribute to a multitude of different scores; the resident behaves differently on different shifts, for example, asleep on night shift but up and about on days. What is the correct way to score them? I believe that a less frequent Braden Scale assessment yields more accurate results. However, we should still complete a Braden Scale on admission, transfer, receiving, and most importantly, with any change in condition.

Aletha Tippett MD's picture
Braden Scale

By Aletha Tippett MD

I was recently asked to speak on best practices for prevention of pressure ulcers for a group of state surveyors. This is an excellent subject and here is how I would address it:

Mary Ellen Posthauer's picture

By Mary Ellen Posthauer RDN, CD, LD, FAND

Since we are fast approaching the deadline for the national elections, I decided to join the fray and campaign for accurate completion of the Braden Scale nutrition sub-score. The Centers for Medicare and Medicaid Services (CMS), Minimum Data Set (MDS) 3.0 Section M, Skin Conditions requires pressure ulcer risk assessment. Nursing facilities may use a formal assessment instrument such as the Braden or Norton tool to determine pressure ulcer risk. The most commonly used pressure ulcer assessment tool is the Braden Scale and one of the sub-scales is nutrition. Studies completed by Bergstrom and Braden in skilled nursing facilities found that 80% of pressure ulcers developed in two weeks after admission and 90% within three weeks of admission.

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