Braden Scale

For Predicting Pressure Sore Risk

How to use the Braden scale

Each patient is assessed for the following risk factors:

• Sensory Perception

• Moisture

• Activity

• Mobility

• Nutrition

• Friction and Shearing

Each risk factor is rated

on a 1-4 scale

A score of LESS THAN

18 indicates HIGH RISK

Score patients as they are at

that moment in time

Sensory Perception Ability to response meaningfully to pressure-related

discomfort

Score 1 if COMPLETELY LIMITED

Unresponsive to painful stimuli (does not moan

flinch or grasp) due to LOC or sedation OR

limited ability to feel pain over most of body

IE: on paralytics; in coma or stuporous state

Score 2 if VERY LIMITED

responds only to painful stimuli. Cannot

communicate discomfort except by moaning or

restlessness OR has a sensory impairment that

limits the ability to feel pain over 1/2 of body

IE: patients who only moan but can’t commun-

icate pain; patients with paralysis

Sensory Perception Ability to response meaningfully to pressure-related

discomfort

Score 3 if SLIGHTLY LIMITED

Responds to verbal commands but cannot always

communicate discomfort or need to be turned OR

has some sensory impairment which limits ability

to feel pain or discomfort in 1-2 extremities

IE. Severe arthritics unable to turn, stroke patient

Score 4 if NO IMPAIRMENT

Responds to verbal commands. Has no sensory

deficits which would limit ability to feel or voice

pain or discomfort

IE: walkie-talkie

Moisture: Degree to which skin is exposed to moisture

ie. Incontinence, perspiration, drainage

Score 1: if Constantly Moist

Skin is kept moist almost constantly by perspiration,

urine, etc. Dampness is detected every time patient

is moved or turned

IE. C diff patient, frequently incontinent of urine or

stool

Score 2: Often Moist

Skin is often but not always moist. Linen must be

changed at least once a shift

IE: Incontinent of urine, copious drainage from

wound

Moisture: Degree to which skin is exposed to moisture

ie. Incontinence, perspiration, drainage

Score 3: Occasionally Moist

Skin is occasionally moist, requiring an extra

linen change approximately once a day

IE. Diaphoretic. Draining wound

Score 4: Rarely Moist

Skin is usually dry: linen only requires changing

at routine intervals

IE. Patient continent of urine, no drainage or

perspiration

Activity Degree of physical activity

Score 1: Bedfast

Confined to

bed

Score 2: Chairfast

Ability to walk severely limited

or nonexistent. Cannot bear

own weight and / or must be

assisted into a chair

or wheelchair

Score what the patient is doing NOT

what they are capable of doing

Activity Degree of physical activity

Score 3: Walks Occasionally

Walks occasionally during the

day but for very short distances

with or without assistance.

Spends majority of each shift

in bed or chair

IE. CHF patient with activity

intolerance

Scores 4: Walks Frequently

Walks outside the room at least twice

a day and inside room at least once

every 2 hours during waking

IE Walkie talkie

Mobility Ability to change and control body position

Scores 1: Completely immobile

Does not make even slight changes

in body or extremity position without

assistance

IE. Paralyzed, severe stroke patient

Scores 2: Very Limited

makes occasional slight changes in

body or extremity position but unable

to make frequent changes or significant

changes independently

IE. Fractured hip patient

Score what the patient is doing NOT

what they are capable of doing

Mobility Ability to change and control body position

Scores 3: Slightly Limited

Makes frequent though slight changes

in body or extremity position independently

Scores 4: NO Limitations

Makes major and frequent changes in

position without assistance

Nutrition Usual food intake pattern

Scores 1 : Very Poor

Never eats a complete meal.

Rarely eats more than 1/3 of

any food offered. Eats 2 servings

or less protein (meat or dairy products)

per day. Takes fluids poorly, no

liquid dietary supplements OR is NPO

or Clear liquids or IVs for >5 days

Scores 2: Probably Inadequate

Rarely eats a complete meal. Generally

eats only 1/2 of food offered, Protein intake

includes only 3 servings of meat or dairy

products per day. Occasionally takes a

dietary supplement OT receives less than

optimal amount of liquid diet or tube feeding

IE. Patient just starting on tube feeding

1/3

Nutrition Usual food intake pattern

Scores 3: Adequate

Eats over 1/2 of most meals.

Eats 4 servings of protein (meat

and dairy products) each day.

Occasionally will refuse a meal but

will usually take a supplement OR

is on a Tube feeding or TPN regiment

which meets most nutritional needs

IE. Tube feeding at 80ml/hr

Score 4: Excellent

Eats most of every meal. Never

refuses a meal. Eats 4 or more servings

meat or dairy. Occasionally eats between

meals Doesn’t need supplements

IE. Healthy eater

Friction and Shearing

Score 1: 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 max assistance.

Spasticity, contractures, or

agitation leads to almost

constant friction

Friction and Shearing Score 2: Potential Problem

Moves feebly or requires minimal

assistance. During a move, skin

probably slides against sheets/

devices. Maintains good position

in bed most of the time but

occasionally slides down

Scores 3: No Apparent Problem

Moves in bed independently and has

sufficient muscle strength to lift up

completely during a move. Maintains

good position in bed at all times

Transparent Dressings

Transparent dressings

are constructed from a

thin film backing coated

with a hypoallergenic,

water resistant adhesive.

They allow for gas and vapor

exchange while providing a

barrier to outside contaminants.

Change for leaking

May be left in place for up to

7 days

Hydrocolloid

Moisture retentive

adhesive dressing

composed of a flexible

crosslinked adhesive

mass containing

gelatin,pectin,

carboxymethylcellose

particles

Reassess after 48 to

72hrs

Hydrogels

•Contains mostly water

with some polymers

• Used to autolytically

debride a wound.

• Used for partial or full

thickness wounds

• Used for thermal burns

• Used for dry or lightly

exudating wounds

Foam Dressings

• Semipermeable hydrophilic

polyurethane foam dressing

• Reapply dressing when it becomes

loosened, saturated, or soiled

Special order product

with consult to skin care

nurse.

Ex: Lyofoam, Curaforam, CarraSnart, VigiFoam

Calcium Alginates

• These are non woven

dressings made from

calcium alginate fibers.

• Alginates form a gelatinous

mass as they absorb wound

exudate, promoting a moist

healing environment

Special order that requires

a skin care consult (comes in ropes or pads)

Ex: Sorbsan, Kaltostatm Carrasorb, Curasorb

Gift from the sea! Calcium Alginates are made of

seaweed and absorb 20 times their weight

Wound Solutions

• Normal Saline

• Hydrogels

• Betadine

• Acetic Acid

• Hydrogen Peroxide

• Dakins Solutions

Normal Saline

• isotonic the bodily fluids

• friendly to tissue cells

• provides a moist

environment for

wound healing

• no antibacterial coverage

• ideal for wound cleansing

Hydrogels

• adds moisture to maintain a moist wound

environment.

• Its slightly acidic nature promotes healing

• Provides more moisture than normal saline so

do not disturb wound bed more than every

12 hours

Betadine

• Provides broad spectrum effectiveness when

used on intact skin or small clean wounds

• Can be toxic to fibroblasts in normal dilutions

(if used it should be 1/4 to 1/2 strength

• Not always effective in infected wounds

• Long term use in large numbers may cause

iodine toxicity

Acetic Acid

• Can be effective against Pseudomonas aeruginosa

in superficial wounds

• Toxic to fibroblasts in standard dilutions

• May change the color of exudate, which may

provide false assurance that the infection has been

eliminated

Hydrogen Peroxide

• Provides mechanical cleansing and some

debridement by effervescent action

• Toxic to fibroblasts

• Can cause ulceration of newly formed tissue

• DO NOT use to pack sinus tract (can cause

air embolism

• DO NOT use for forceful irrigation (can cause

subcutaneous emphysema)

Dakin’s solution

• Effective against Staphylococcus and

Streptococcus species

• Dissolves necrotic tissue

• Controls odor

• Toxic to fibroblasts in normal dilutions

• Protect intact surrounding skin to prevent

breakdown

Dressings

• Gauze

• Kerlix

• ABD pads

• Kling

• Telfa

• Adaptic

• Vaseline Gauze

• NU gauze

Gauze

• IE. Gauze sponges

• Cotton woven gauze

• Well suited for dressing, cleaning, packing, and debriding wounds

Kerlix

• Fluff woven gauze that offers bulk and high absorbency.

• Secondary dressing used to secure primary dressing without tape

• Ideal for wrapping extremities

ABD pads

• IE. Kendall Tendersorb

• 3 layer soft outer non- woven layer with fluff filler to absorb and disperse fluid and a wet proof moisture barrier to retard fluid strike through

• edges slated to prevent lint residue

Telfa- Non-adherent Dressing

• Cotton pad

• Won’t disrupt healing tissue by sticking to wound.

• Ideal as primary dressing for lightly draining wounds

Adaptic Dressing

• Oil emulsion blend impregnated into open mesh knitted fabric dressing

• Non-Adhering to wound site

• Allows free drainage of exudate away from wound

Vaseline Gauze

• Non adherent

• impregnated with 3% Bismuth tribromo- phenate in a petrolatum blend on a fine mesh gauze

• Use when chest tubes discontinued for an occlusive dressing.

• Do not use a chest tube daily dressing as petroleum can cause maceration

NU Gauze

• 100% cotton fine mesh gauze ideal for wet to dry packing

• Helps to control bleeding and prevent pooling of wound fluid

Types of Debridement

Debridement: is indicated when necrosis or slough is present

• Autolytic: (Mechanical)

• Sharp: (Surgical)

• Enzymatic: (Chemical)

Autolytic Debridement

Coverage of an ulcer with dressing materials

that retain wound moisture to allow the body’s

own enzymes in wound fluid to digest dead

tissue. (wet to dry drssings)

+ selectively debrides necrotic tissue, May be

used for patients who cannot tolerate other

forms of debridement

- takes longer than other debridement

methods

Progress should be visible in 2-3 days

Sharp: (Surgical)

Surgical removal of dead tissue

+ immediate treatment of choice if patient is septic

- non selective, painful, requires specialized skill

Enzymatic: (Chemical)

Ex: Collagenase Santyl

Loosens necrotic debris

Takes longer than sharp

debridement but may be

faster than autolytic

Advanced Wound Care

• Compression Bandages

• Wound Pouching

• Negative Pressure Therapy VAC

Compression Bandages

• Reduced blood pressure in superficial venous system

• Aid venous return to the heart

• Reduces edema by reducing the pressure difference between the capillaries and the tissue

• With venous ulcers, these issues must be addressed to heal the wound. Change elastics bandages at least BID to sustain pressure

UNNA Boot

Wound Pouching • Wound pouching is a

way to manage highly exudating wounds that are macerating surrounding tissues or to manage fistulas

• The pouch is cut to fit the opening of the wound and the surrounding skin is protected by the stomadhesive base of the pouch

Negative Pressure Therapy VAC

• Foam dressing placed in wound covered by a film dressing that has sub-atmospheric pressure applied

• Removes edema leading to localized blood flow

• Removes wound fluid, bacterial counts

VAC: Vacuum Assisted Closure

Consists of 5 items:

Machine

Canister

Foam: Black or White

Drape / Dome with

tubing

Tegaderm

Setting machine

Press THERAPY

Press Continuous

Press ON

Machine will default to

125mmGH, adjust

up of down with arrows

per MD order

Q shift: Check the machine

is ON, Continuous, and

pressure per MD order

Incisional Negative Pressure Therapy

PICO Prevena

The Results

With the assist of Vacuum Assisted Closure,

wounds like this can heal!!!

Intact skin with non-

blanchable redness

of a localized area

usually over a bony

prominence. Presence

of blanchable erythema

or changes to sensation

temperature or firmness

may precede visual

changes

Stage 1

Partial thickness loss

of dermis presenting

as a shallow open

ulcer with a red pink

wound bed, without

slough. May also

present as an intact

or open/ruptured

serum-filled blister.

Stage 2

Full thickness tissue

loss. Subcutaneous

fat may be visible but

bone, tendon or

muscle are not

exposed. Slough

may be present but

does not obscure the

depth of tissue loss.

May include under-

mining and tunneling

Stage 3

Full thickness tissue

loss with exposed

bone, tendon or

muscle. Slough or

eschar may be

present on some

parts of the wound

bed. Often include

undermining

and tunneling.

Stage 4

Full thickness tissue loss

in which the base of the

ulcer is covered by slough

(yellow, tan, gray, green or

brown) and/or eschar

(tan, brown or black)

in the wound bed

Unstageable pressure

injury

Deep tissue

pressure Injury

Purple or maroon localized

area of discolored intact skin

or blood-filled blister due to

damage of underlying soft

tissue from pressure and/or

shear. The area may be

preceded by tissue that is

painful, firm, mushy, boggy,

warmer or cooler as compared

to adjacent tissue

Fecal Incontinence Toolkit

Can be ordered from Inventory

WIPE7905

OR

from your Supply carts

SAGE Dimethicone Wipes Nutrashield Calmoseptine

Flexiseal

Insertion kits from Sue Hoban

on days or Nursing Supervisor

Low Air Loss Rental Mattress

Call 1-800-343-0970 to rent a

First Step Select

BE NOT AFRAID

“ Don’t be afraid to try

something new”

Remember an amateur built

an arc and a whole group of

professionals to build the

titanic !!!