“What’s Your Braden?”

Self-Learning Module

Developed byGarden City Hospital

Professional Nursing Development

Garden City Hospital is an approved provider of continuing nursing education by the Wisconsin Nurses Association, an accredited approver by the American Nurses Credentialing

Center’s Commission on Accreditation.

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“What’s Your Braden?”

General Information Regarding the Program

Successful Completion: To receive 1.5 contact hours, for “What’s Your Braden?”, participants must read the entire self-learning module, complete the post-test with a passing score of >80%, complete/submit an evaluation form and during monthly unit-based skins rounds accurately determine the Braden Score and pressure ulcer prevention interventions for 2 patients.

Conflicts of Interest: The activity planners and presenters for “What’s Your Braden?” reported no relevant financial relationships with commercial interests or conflicts of interest related to their presentations.

Commercial Support: Commercial support was not received for “What’s Your Braden?”

Non-Endorsement of Products: The presence of commercial products does not imply endorsement by Garden City Hospital, Wisconsin Nurses Association, or the American Nurses Credentialing Center’s Commission on Accreditation.

Off-Label Use: All presenters have agreed to disclose to participants prior to their presentations if off-labeled (or unlabeled uses) of commercial products will be discussed during their presentation(s).

Expiration: The expiration date for this educational activity is June 22, 2014. No contact hours will be awarded to participants who submit evaluation forms and post-tests after this date. Please contact Professional Nursing Development with questions.

Thank you

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“What’s Your Braden?”

Purpose of Activity: To identify Braden sub-scores to accurately determine Braden risk levels in order to implement appropriate pressure ulcer prevention interventions.

Objectives of the Program:

Upon completion of this module each nurse will be able to:

1. Define the Braden Scale.2. Discuss the purpose for using the Braden Scale3. Demonstrate use of the Braden Scale with 3 case studies to determine the sub-score and

the over-all risk levels.4. Apply knowledge of the Braden Scale with two patients, in identifying sub-scores, risk

level and interventions for pressure ulcer intervention.

Target Audience: In-patient acute-care Registered Nurses and in-patient rehabilitation Registered Nurses.

Date: June 2012 through June 22, 2014.

To receive 1.5 contact hours, for “What’s Your Braden?”, participants must read the entire self-learning module, complete the post-test with a passing score of >80%, complete/submit an evaluation form and during monthly unit-based skins rounds accurately determine the Braden Score and pressure ulcer prevention interventions for 2 patients. This competency must be completed by June 22, 2014 to receive contact hours.

Planning Committee/Presenters: Susan Karasinski RN, MSN, Allison Mardeuz RN, BSN, Jennifer Kelly RN, BSN, CCRN, Michelle Cooper RN, MSN, Mary Whalen RN, BSN, CWOCN, Amber Marchena RN, Gail Fenech RN, BSN and Carter Blocksma RN, BSN.

Garden City Hospital is an approved provider of continuing nursing education by the Wisconsin Nurses Association, an accredited approver by the American Nurses

Credentialing Center’s Commission on Accreditation.

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The National Pressure Ulcer Advisory Panel (NPUAP) defines a pressure ulcer as

“localized injury to the skin and/or underlying tissue usually over a bony prominence as a result

of pressure or pressure in combination with shear and/or friction” (2007). Pressure ulcer

development crosses the continuum of care from acute hospitalized care to long-term residential

care to home care. It is estimated that the prevalence and incidence of pressure ulcer

development is increasing despite advances in technology related in part to our aging population

and complexity of care.

The high prevalence and incidence rates of pressure ulcers along with the cost of

treatment constitute a substantial burden on all health care systems (Clark, Bradley, Whytock,

Hanfied, Van Dee Wall and Guntry, 2005). It is estimated that pressure ulcer care can increase

nursing time up to fifty percent with treatment costs per ulcer ranging from $10,000 to $86,000

(Clark et. al., 2005). In addition, the preservation of intact skin and the prevention of pressure

ulcers has long been a quality indicator of nursing care. The development of a pressure ulcer can

interfere with a patient’s overall recovery, cause extreme pain, predispose an individual to

infection and in some cases contribute to premature mortality (Reddy, Gill and Rochon, 2006).

As a result, the Institute for Health Care Improvement (IHI) and the Joint Commission of

Accreditation of Health Care Organization (JAHCO) have each adapted pressure ulcer

prevention as one of their National Patient Safety Goals (Strategies for Preventing Pressure

Ulcers, 2008). Further the Centers for Medicare and Medicaid Services (CMS) have identified

pressure ulcers as an adverse event and as of October 2008, hospitals are no longer being

reimbursed for care related to pressure ulcer development (Armstrong, Ayello, Fowler, Krasner,

Levine, Sibbald and Smith, 2008).

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Identification of individuals at risk for pressure ulcer development along with initiating

preventive measures is an important means of reducing pressure ulcer prevalence and incidence

(Ayello and Braden, 2002). The importance of accurate, consistent assessment using a formal

tool cannot be overstated. The Braden Scale provides a reliable valid tool for pressure ulcer risk

assessment when used by competently trained nurses. It is the first step in pressure ulcer

prevention. Inaccurate assessments either over predicting or under predicting risk can potentially

alter patient safety as well as institute unnecessary costly preventive measures.

The Braden Scale is a risk assessment tool which was developed based on the etiology of

pressure ulcer formation. It evaluates patients in six sub-categories; sensory perception,

mobility, activity, moisture, nutrition and friction and shear. Each sub-category is given

descriptors allowing the user to assign an appropriate number based on the patient’s assessment.

The numbers range from one to four with the exception of the sub-category of friction and shear,

which is rated from one to three. The scores are totaled and the final score assigns a level of

pressure ulcer development risk from 6 to 23. The scores are then divided into levels, which can

assist in determining pressure ulcer development risk. The lower the total score- the greater the

risk. Matching the patient’s clinical status to the subscale descriptors on the Braden Scale

ensures that the risk assessment is accurate and reliable (Magnan and Maklebust, 2009). It is

important to refer to the Braden Scale descriptors without using shortcuts or modifications.

Based on the risk assessment, prevention protocols should be initiated and a Plan of Care

developed. For example, patients assessed with a total score of 18 or below as well as those that

have pressure ulcers should also have a Nutritional Consult and the nurse should consider the

need for a Transthyretin (TTR) and Albumin levels. The following refers to the risk of pressure

ulcer development based on total score of the Braden Scale individual descriptors:

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23-19 No Risk

18-15 At Risk

14-13 Moderate Risk

12-10 High Risk

9-6 Very High Risk

It is very important to keep in mind that a skin assessment and pressure ulcer assessment,

although they may look at similar things, they are two different assessments with different

purposes. The skin assessment looks at temperature, color, moisture, turgor and integrity not the

risk of pressure ulcer development (Baranoski and Ayello, 2008). The pressure ulcer

assessment, considers factors that contribute to skin breakdown when points of the body are

placed under pressure. In many instances, the factors that contribute to skin breakdown and the

amount of pressure applied to the body can be altered to avoid pressure ulcers.

The following will provide the specific descriptors and examples of how to rate patients

in the sub-categories of the Braden Scale. Keep in mind that prevention interventions should be

initiated based on both the total score and the lower scoring sub-categories as well. The

prevention interventions can be grouped together based on the sub-categories such as those listed

in “Intervention Guidelines for Braden Risk Factors” (Magnan and Maklebust, 2008).

Intervention Guidelines for Braden Risk FactorsBraden Level of Risk Score

Minimal Risk-Score 19-23 Moderate Risk-Score 13-18 High Risk-Score 10-12 Consider WCOCN consult Very High Risk Score <9

Based on the Braden Level of Risk Score and the Braden Subscale Scores use the guidelines below to assist in providing appropriate interventions.

Preventive interventions for low Braden subscale scores on sensory perception, mobility and activity. A low score is indicated when the value is less than 4 in the subscales of sensory perception, mobility

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and activity.

Use a pressure reducing support surface.

Apply soft care mattress Consider chair cushion when up in chair.Implement a whole body repositioning schedule

Post a turning a clock in the room.

Use a 30-degree lateral side-lying angle to avoid positioning on sacrum and trochanter simultaneously.

Use pillows, wedges, popliteal support or vascular boots to float heels off of the bed and to bridge between knees and ankles.

Instruct patient/family to protect from the effects of pressure.

Preventive interventions for low Braden subscale scores on moisture, nutrition and friction and shear. A low score is indicated when the value is less than 4 in the subscales of moisture, nutrition and a value less than 3 for the subscale of friction and shear.

Gently cleanse skin as soon as it is soiled

Use incontinence cleansing foam Follow with a protective barrier cream with each cleansing.Use under pads to wick moisture away.

Avoid the use of diapers.Keep the HOB elevated to 30-degrees or lower to avoid friction and shearing from patient sliding down.

Use a lift sheet or MaxiSlide to lift (not drag) patient in bed.

Use an overhead trapeze to assist patient to lift buttock to avoid friction burns from dragging across bed sheets.

Consult dietitian for Braden scores 18 or less.

Consider nutritional supplement – Juvan, Ensure, Boost Instruct patient/family the relationship of good nutrition and healthy skin.

Used with permission from J. Maklebust. Magnan, M. & Maklebust, J. 2008. The nursing process and pressure ulcer prevention: making the connection. Advances in Skin and Wound Care. 22(2), pp 83-94.

Sensory Perception

Decrease sensory perception predisposes the patient to prolonged and intense pressure

due to the lessened ability to perceive or respond to the discomfort of pressure. The sensory

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perception portion of the Braden Scale assesses the “ability to respond meaningfully to pressure

related discomfort” (Ayello and Braden, 2002, p126). Each assessment includes a scoring of the

patient’s sensory ability. Loss of sensation interferes with the patient’s perception of pain.

Therefore, the need to change position or shift their weight is not recognized, even if the person

is able to change their weight physically.

Some examples of this would include patients who are post-stroke, cerebral hemorrhage,

narcotic poisoning, spinal cord injury, neuropathy and post-operative general or epidural

anesthesia patients.

Using the Braden Scale sub-category Sensory Perception answer the following question:

Sensory Perception

Ability to respond meaningfully to pressure-related discomfort

1. Completely Limited

Unresponsive (does not moan, flinch or grasp) to painful stimuli, due to diminished level of consciousness or sedation.

ORLimited ability to

feel pain over most of body

2. Very Limited

Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness.

ORHas a sensory impairment which limits the ability to feel pain or discomfort over ½ of body.

3. Slightly Limited

Responds to verbal commands, but cannot always communicate discomfort or the need to be turned.

ORHas some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.

4. No Impairment

Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.

1. A patient arrives on the unit following epidural anesthetic used during surgery. Epidural

analgesia is being used. What would the Sensory Perception score on the Braden Scale?

be?

A. 1-Completely Limited

B. 2-Very Limited

C. 3-Slightly Limited

D. No Impairment

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Answer: The patient, after epidural anesthesia, would have “very limited” sensory

perception and score #2. As the epidural anesthetic wears off, the sensory perception

should improve. Patients with epidural analgesia ALONE without epidural anesthesia

have some sensory impairment but not limiting “the ability to feel pain or discomfort

over ½ of the body” Therefore the score with epidural analgesia ALONE may be #3.

Moisture

Moisture is an essential clue in the assessment of risk for pressure ulcer development. It

is identified in several risk assessment scales. In the Braden Scale, moisture is defined: “the

degree to which the skin is exposed to moisture” (Ayello and Braden, 2002, p126). Moisture

may be in the form of urine, feces, perspiration or uncontained drainage from a wound or fistula.

Moisture from whatever source can support the risk for pressure ulcer development.

Using the Braden Scale sub-category Moisture answer the following question:

Moisture

Degree to which skin is exposed to moisture

1. Constantly Moist

Skin is kept moist almost constantly by perspiration, urine etc. Dampness is detected every time patient is moved or turned.

2. Very Moist

Skin is often, but not always, moist. Linen must be changed at least once a shift.

3. Occasionally Moist

Skin is occasionally moist, requiring an extra linen change approximately once a day.

4. Rarely Moist

Skin is usually dry; linen only requires changing at routine intervals.

2. Your patient is incontinent of urine every time they cough or sneeze. What would the

Braden Scale score be for Moisture?

A. 1-Constantly Moist

B. 2-Very Moist

C. 3-Occasionally Moist

D. 4-Rarely Moist

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Answer: The moisture score is #3. The skin is occasionally moist since the patient is not

going to cough and sneeze all of the time but enough to require extra linen changes or

incontinent pad changes.

3. Your patient has C-diff and is not a candidate for a flexiseal. They have a stool at least

every 2 hours requiring frequent linen changes. What is the Braden Scale score for

Moisture?

A. 1- Constantly Moist

B. 2-Very Moist

C. 3-Occassionally Moist

D. 4-Rarely Moist

Answer: Linen changes are frequent due to moisture and stool which would make the

Braden Scale moisture score # 1.

Activity

This sub-category indicates the “degree of physical activity” (Ayello and Braden, 2002,

p126).

Using the Braden Scale sub-category Activity answer the following question:

Activity

Degree of physical activity

1. Bedfast

Confined to bed.

2. Chair fast

Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair.

3. Walks Occasionally

Walks occasionally during day, but for very short distances with or without assistance. Spends majority of each shift in bed or chair.

4. Walks Frequently

Walks outside room at least twice a day and inside room at least once every two hours during waking hours.

4. The Activity Scale of the Braden Scale assesses the individual’s degree of physical

activity. Which category on the Braden Scale is the correct score for a patient with

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bathroom privileges?

A. 1-Bedfast

B. 2-Chairfast

C. 3-Walks Occasionally

D. 4-Walks Frequently

Answer: The patient is scored #3. The category “walks occasionally” denotes that the

patient walks short distances only, spends most of the day in bed or chair.

5. Your patient has just returned from hip surgery and the orders read to keep the

patient ABR until evaluated by Physical Therapy in the morning. Which number on the

Activity Scale is the correct score for the patient that is ABR.

A. 1-Bedfast

B. 2-Chairfast

C. 3-Walks Occasionally

D. 4-Walks Frequently

Answer: The patient is scored #1. Although the patient may have walked into the

hospital in the morning prior to surgery, the Braden Scale is done in “real time” and

currently your patient is ABR. Once the patient is up and ambulating the score will be

changed according to the patient’s current activity.

Mobility

Mobility on the Braden Scale is defined as “ability to change and control body position”

(Ayello and Braden, 2002, p126). An impairment in mobility is the decreased ability to shift

body weight and change positions. This limitation increases the likelihood of prolonged pressure

with subsequent pressure ulcer formation. Turn schedules (example: turn every 2 hours and prn)

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in nursing practice are the result of research validating the significance of altered mobility in

pressure ulcer development.

Mobility

Ability to change and control body position.

1. Completely Immobile

Dose not make even slight changes in body or extremity position without assistance.

2. Very Limited

Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

3.Slightly Limited

Makes frequent though slight changes in body or extremity position independently.

4.No Limitations

Makes major and frequent changes in position without assistance.

6. A stroke patient with residual bilateral weakness is on a turning schedule every 2 hours

which provides the patient with movement at regular intervals. In between turns, the staff

observes that the patient is able to move her extremities somewhat; however, her trunk

remains in the same position. What Mobility Score would be correct?

A. 1-Completely Immobile

B. 2-Very Limited

C. 3-Slightly Limited

D. 4-No Limitations

Answer: Since the patient is unable to move their trunk without assistance, but is able to

make slight changes in extremity position, this patient is scored a #2.

7. You have just received a patient from the Emergency Room with a diagnosis of rule out MI.

He is very anxious and moving all around in the bed. What Mobility Score would be most

accurate?

Answer: Since the patient is able to move without assistance, this patient is scored a #4.

Nutrition

The intrinsic factor on the Braden Scale for Pressure Sore Risk is nutrition. The Braden

Scale and most other pressure ulcer risk assessment scales include decreased nutrition as a risk

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factor. Poor general nutrition associated with loss of weight and muscular atrophy results in loss

of subcutaneous tissue and muscle bulk. This reduces the mechanical padding between the skin

and underlying bone, increasing the risk of pressure ulcer development.

The nutritional deficiencies most often considered in pressure ulcer research are

hypoproteinemia, ascorbic acid deficiency and trace mineral deficiencies. Lack of elements

interfere with normal tissue quality and integrity, particularly collagen synthesis. Collagen is

important for providing the structural support necessary for tissue integrity.

In the Braden Scale, nutrition is defined as the “usual food intake pattern” (Ayello and

Braden, 2002, p126) over a period of two to three days. This sub-category requires somewhat of

professional judgment of the nurse. If the patient is newly admitted, the nurse can question the

patient or significant other regarding normal dietary intake. If a liquid diet or liquid supplement

is used the nurse can assess the actual quantity taken each day. If the patient is NPO for surgery

or a procedure the Braden Score would still depend on intake for the last three days. If the

patient is on tube feedings the maximum score for that patient is 3 since tube feedings rarely

match dietary intake. If the patient is just beginning tube feedings and is not up to full strength,

rate them a 1 or 2 depending on how they have been doing for the previous 2-3 days (Bergstrom,

2011).

The patient that is NPO, on clear liquids or IV fluids for more than 5 days should have a

Nutrition consult. It is the responsibility of the nurse to notify Nutritional Services if the

patient’s score is “probably inadequate” on the Braden Scale. A nutrition score on the Braden

Scale requires critical judgment of the nurse caring for that patient and may not be as obvious of

an answer as the other sub-categories.

Nutrition1. Very Poor

Never eats a

2. Probably Inadequate

Rarely eats a

3. Adequate

Eats over half of

4. Excellent

Eats most of every

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Usual food intake pattern

complete meal. Rarely eats more than ½ of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement.

ORIs NPO and or maintained on clear liquids or IVs for more than 5 days.

complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement.

ORReceives less than optimum amount of liquid diet or tube feeding.

most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered.

ORIs on a tube feeding or TPN regimen which probably meets most of nutritional needs.

meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.

8. A patient is admitted from home. He is currently NPO for surgery today. The

patient’s usual daily diet consists of:

Breakfast: toast and eggs (1 or 2) and coffee

Lunch: coffee, ham and cheese sandwich, apple

Dinner: coffee, salad, corn, potato, tuna or beef casserole

What is the patient’s Nutrition Score on the Braden Scale?

A. 1-Very Poor

B. 2-Probably Inadequate

C. 3-Adequate

D. 4-Excellent

Answer: The diet would be considered excellent; a score of 4. It includes at least 4

proteins (eggs, ham, cheese and a protein in the casserole).

Note that one average protein serving equals; 1 cup of milk or 1 egg or 1 ounce of cheese

or 4 ounces of meat/poultry.

9. A patient has been admitted with a severe stroke and an inability to swallow safely.

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She has had an IV D5W at a 100 ml/hour for the past 2 days. Yesterday afternoon,

tube feedings were begun via a PEG. The patient is now receiving ¾

strength standard tube feeding at 50ml/hour.

What is the patient’s Nutrition Score on the Braden Scale?

A. 1-Very Poor

B. 2-Probably Inadequate

C. 3-Adequate

D. 4-Excellent

Answer: The patient has just started on tube feeding and is not receiving full strength of

the tube feeding therefore they would not have their nutritional needs met at this time.

The score would be 2. This patient’s nutritional score may change daily related to

changes in strength and rate of the tube feeding and needed reassessment of the patient’s

tolerance of the tube feeding.

Friction and Shear

The final factor on the Braden Scale is friction and shear. These are mechanical forces

related to pressure ulcer development. Friction is defined as the resistance to movement in a

parallel direction or when two surfaces move across on another (Barnowski and Ayello, 2010).

Examples of friction include spastic movement, casts or other orthopedic devices. Shear on the

other hand occurs when pulling in one direction results in movement in the opposite direction

(Barnowski and Ayello, 2010). Shear forces usually involve movement as well as compression

or compromised blood flow causing tissue damage. For example, when the head of the bed is

elevated and the skin and tissue slide in opposite directions of the pelvis while compromising

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blood flow. Complete lifting without sliding against the bedding is difficult; therefore, transfers

from bed to chair and back can also create friction and shear.

Friction and Shear1. Problem

Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction.

2. Potential Problem

Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.

3. No Apparent Problem

Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.

10. What score would be given for Friction and Shear when assessing an agitated patient

who is constantly sliding down in bed and tugging at the bedding and everything else in

reach?

A. 1-Problem

B. 2-Potential Problem

C. 3-No Apparent Problem

Answer: Friction and shear score is #1. Rubbing and/or pulling at bedding or restraints is a

constant source of friction and/or shear.

11. Another patient is semi-comatose and requires staff to reposition him every two

hours would have what score for Friction and Shear?

A. 1-Problem

B. 2-Potential Problem

C. 3-No Apparent Problem

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Answer: The score is again #1. Body weight is not a factor in friction and shear. Inability

to relieve friction and shear pressure due to lack of spontaneous position changes places this

patient as a 1 on the Braden Scale. A patient able and willing to maintain good position

between assisted position changes or who is weak or slides down occasionally in bed or chair

would be scored a 2 for potential problem for friction and shear.

Patients on the Medical-Surgical, Oncology, ICU/CCU and Rehabilitation units will be

assessed for pressure ulcer risk factors using the Braden Scale upon admission in

Invision/Net Access system patient factors on the History Assessment/Admission Database.

If the assessment is deferred due to the patient’s condition, it must be completed within 24

hours of admission. Braden reassessments are also done every 12 hours and with any

physical or cognitive deterioration in the patient’s condition and documented on the Clinical

Management Record. In addition, all of the patients on these units are assessed monthly

during unit Skin Rounds with the Unit Skin Champion, Staff Nurse assigned to the patient,

the Patient Care Assistant/Technical Partner and the Certified Wound, Ostomy, Continence

Nurse.

Summary

The extent to which the Braden Scale is competently used in the acute care setting cannot be

over emphasized. Braden scale assessment is the first step in the identification of pressure ulcer risk

facilitating appropriate pressure ulcer prevention measures and cost effective use of health care

resources.

References

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Armstrong, D., Ayello, E., Capitulo, K., Fowler, E., Krasner, D., Levien, J., Sibbald, G., &

Smith, A. (2008). New opportunities to improve pressure ulcer prevention and

treatment: implications of the cms inpatient hospital care present on admission

indicators/hospital-acquired conditions policy. A consensus paper from the

International Expert Wound Care Advisory Panel.

Ayello, E, & Braden, B. (2002). How and why to do pressure ulcer risk assessment.

Advances in Skin and Wound Care, 15(3), 125-133.

Baranoski, S. & Ayello, E. (2010). Wound care essentials: Practice and principles (2nd ed.).

Philadelphia, Lippincott Williams & Wilkins.

Clarke, H., Bradley, C., Whytock, S., Handfield, S., Van der Wal, R., & Gundry, S. (2005).

Pressure ulcers: implementation of evidence-based nursing practice. Journal of

Advanced Nursing, 49(6), 578-590.

Magnan, M., & Maklebust, J. (2009). The nursing process and pressure ulcer prevention:

Making the connection. Advances in Skin and Wound Care, 22(2), 83-91.

National Pressure Ulcer Advisory Panel (2007). Updated staging system NPUAP, Retrieved

February 2, 2009 from http://wwwnpuap.org/pr2.htm

Reddy, M., Gill, S., & Rochon, P. (2006). Preventing pressure ulcers: a systematic review.

JAMA, 296(8), 974-984.

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