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Several factors place a client at risk for developing a pressure injury, in addition to shear and friction. These factors include decreased sensory perception, increased moisture, decreased activity, impaired mobility, and inadequate nutrition. The Braden Scale is a standardized, evidence-based assessment tool commonly used in health care to assess and document a client’s risk for developing pressure injuries. See Figure 10.21[1] for an image of a Braden Scale. Risk factors are rated on a scale from 1 to 4, with 1 being “completely limited” and 4 being “no impairment.” The scores from the six categories are added, and the total score indicates a client’s risk for developing a pressure injury based on these ranges:

  • Mild risk: 15-18
  • Moderate risk: 13-14
  • High risk: 10-12
  • Severe risk: less than 9
Image showing the Braden Scale
Figure 10.21 Braden Scale

How to Score the Braden Scale

Each risk factor on the Braden Scale is rated from 1 to 4 based on the client’s assessment findings. When using the Braden Scale, start with the first category and review each description listed across the row for each of the ratings from 1 to 4, and choose the one that best describes the client’s current status. Continue this process for all rows. Add all six numbers to determine a total score, and then use the total score to determine if the client is at mild, moderate, high, or severe risk for developing a pressure injury. The lower the score, the higher the risk of developing a pressure injury. Additionally, customized nursing interventions are implemented based on the rating in each category. The lower the score, the more aggressive actions are taken to prevent or heal a pressure injury. Descriptions of the ratings from 1-4 for each risk factor, along with targeted interventions for each rating, are further described in the following subsections.

Sensory Perception

The sensory perception risk factor is defined as the ability to respond meaningfully to pressure-related discomfort. If a client is unable to feel pressure-related discomfort and respond to it appropriately by moving or reporting pain, they are at high risk of developing a pressure injury. This risk category describes two different issues that affect sensory perception. The first description refers to the client’s level of consciousness, and the second description refers to the client’s ability to feel cutaneous sensation. See Table 10.5a for a description of each level of risk from 1-4 with associated interventions for each level.[2]

Table 10.5a Descriptions and Interventions by Level of Risk for Sensory Perception

Assessment Category Rating Description Interventions
Sensory Perception 4–No Impairment

Responds to verbal commands. Has no sensory deficit that would limit ability to feel or voice pain or discomfort.
  • Encourage the client to report pain over bony prominences.
  • Check heels daily.
Sensory Perception 3–Slightly Limited

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

OR

Has some sensory impairment that limits ability to feel pain or discomfort in 1 or 2 extremities.
  • Assess and inspect skin every shift. Pay attention to heels.
  • Elevate heels and use protectors.
Sensory Perception 2–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 or discomfort over half of the body.

 All interventions mentioned in 3–Slightly Limited plus:

  • Consider specialty mattress or bed.
Sensory Perception 1–Completely Limited

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

OR

Limited ability to feel pain over most of the body.

 All interventions mentioned in 2–Very Limited plus:

  • Use pillows between knees and bony prominences to avoid direct contact.

Moisture

The moisture risk factor is defined as the degree to which skin is exposed to moisture. Prolonged exposure to moisture increases the probability of skin breakdown. Moisture can come from several sources, such as perspiration, urine incontinence, stool incontinence, or wound drainage. Frequent surveillance, removal of wet or soiled linens, and use of protective skin barriers greatly reduce this risk factor. See Table 10.5b for specific interventions for each level of risk.[3]

Table 10.5b Interventions by Level of Risk for Moisture

Rating Description Interventions
Moisture

 

 4–Rarely Moist

Skin is usually dry; linen only requires changing at routine intervals.
  • Encourage the client to use lotion to prevent skin cracks.
  • Encourage the client to report any moisture problem (such as under breasts).
Moisture

 

 3–Occasionally Moist

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

 All interventions mentioned in 4–Rarely Moist plus:

  • Use moisture barrier ointments (protective skin barriers).
  • Moisturize dry unbroken skin.
  • Avoid hot water. Use mild soap and soft cloths or packaged cleanser wipes.
  • Routinely check incontinence pads.
  • Avoid use of adult diapers but if necessary, check frequently (every 2-3 hours) and change as needed.
  • If stool incontinence, consider bowel training and toileting after meals.
Moisture

 

 2–Often Moist

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

 All interventions mentioned in 3–Occasionally Moist plus:

  • Check incontinence pads frequently (every 2-3 hours).
  • Consider a low air loss bed.
Moisture

 

 1–Constantly Moist

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

 All interventions mentioned in 2–Often Moist plus:

  • Assess and inspect skin every shift.
  • Check incontinence pads frequently (every 2-3 hours) and change as needed.
  • Apply condom catheter if appropriate.
  • If stool incontinence, consider bowel training and toileting after meals or rectal tubes if appropriate.

Activity

The activity risk factor is defined as the degree of physical activity. For example, walking or moving from a bed to a chair reduces a client’s risk of developing a pressure injury by redistributing pressure points and increasing blood and oxygen flow to areas at risk.

Level of activity is defined by how frequently the client is able to get out of bed, move into a chair, or ambulate with or without help. See Table 10.5c for a description of each level of risk from 1-4 with associated interventions for each.[4]

Table 10.5c Descriptions and Interventions by Level of Risk for Activity[5]

Assessment Category Rating Description Interventions
Activity

 

 4–Walks Frequently

Walks outside the room at least twice a day and inside the room at least once every two hours during waking hours.
  • Encourage ambulation outside the room.
  • Check skin daily.
  • Monitor balance and endurance.
Activity

 

 3–Walks Occasionally

Walks occasionally during the day, but for very short distances, with or without assistance. Spends the majority of each shift in bed or chair.
  • Provide a structured mobility plan.
  • Consider a chair cushion.
  • Consider physical therapy consult.
Activity

 

 2–Chair Fast

Ability to walk is severely limited or nonexistent. Cannot bear their own weight and/or must be assisted into chair or wheelchair.
  • Consider a specialty chair pad.
  • Consider postural alignment, weight distribution, balance, stability, and pressure relief when positioning individuals in chairs or wheelchairs.
  • Instruct the client to reposition every 15 minutes when in the chair.
  • Stand every hour.
  • Pad bony prominences with foam wedges, rolled blankets, or towels.
  • Consider physical therapy consult for conditioning and wheelchair assessment.
Activity

 

 1–Bedfast

Confined to bed.
  • Perform skin assessment and inspection every shift.
  • Position prone if appropriate or elevate head of bed no more than 30 degrees.
  • Position with pillows to elevate pressure points off the bed.
  • Consider specialty beds.
  • Elevate heels off bed and/or use heel protectors.
  • Consider physical therapy consult for conditioning and wheelchair assessment.
  • Turn/reposition every 1-2 hours.
  • Post turning schedule.
  • Teach or do frequent small shifts of body weight.

Mobility

The mobility risk factor is defined as the client’s ability to change or control their body position. For example, healthy people frequently change body position by rolling over in bed, shifting weight in a chair after sitting too long, or by moving their extremities. However, tissue damage will occur if a client is unable to reposition on their own power unless caregivers frequently change their position. See Table 10.5d for interventions for each level of risk from 1-4.[6]

Table 10.5d Interventions by Level of Risk for Mobility[7]

Assessment Category Rating Description  Interventions
Mobility

 

 4–No Limitations

Makes major and frequent changes in position without assistance.
  • Check skin daily.
  • Encourage ambulation outside the room at least twice daily.
  • No interventions required.
Mobility

 

 3–Slightly Limited

Makes frequent though slight changes in body or extremity position independently.
  • Check skin daily.
  • Turn/reposition frequently.
  • Teach frequent small shifts of body weight.
  • Consult physical therapy for strengthening/conditioning.
  • Use a gait belt for assistance.
Mobility

 

 2–Very Limited

Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.
  • Perform skin assessment and inspection every shift.
  • Turn/reposition 1-2 hours.
  • Post turning schedule.
  • Teach or do frequent small shifts of body weight.
  • Elevate heels.
  • Consider a specialty bed.
Mobility

 

 1-Completely Immobile

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

 Same interventions as for 2–Very Limited

Nutrition

Adequate nutrition and fluid intake are vital for maintaining healthy skin. Protein intake, in particular, is very important for healthy skin and wound healing. The nutrition risk factor is defined by two categories of descriptions. The first category measures the amount and type of oral intake. The second category is used for clients receiving tube feeding, total parenteral nutrition (TPN), or are prescribed clear liquid diets or nothing by mouth (NPO). See Table 10.5e for interventions for each level of risk from 1-4.[8]

Table 10.5e Interventions by Level of Risk for Nutrition[9]

Assessment Category  Rating Description  Interventions
Nutrition

 

 4–Excellent

Eats most of every 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.
  • Move the client out of bed for all meals.
  • Provide food choices.
  • Offer nutrition supplements.
  • Discuss a plan with the provider if the client is NPO for greater than 24 hours.
  • Record dietary intake.
Nutrition

 

 3–Adequate

Eats over half of most meals. Eats a total of 4 servings of protein (meat and dairy products) each day. Occasionally refuses a meal, but will take a supplement if offered

OR

Is on a tube feeding or TPN regimen that most likely meets most of nutritional needs
  • Observe and monitor nutritional intake.
  • Discuss a plan with the provider if the client is NPO for greater than 24 hours.
  • Record dietary intake and I&O if appropriate.
Nutrition

 

 2–Probably Inadequate

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

OR

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

 All interventions mentioned in 3–Adequate plus:

  • Encourage fluid intake as appropriate.
  • Obtain nutritional/dietary consult.
  • Offer nutrition supplements and water.
  • Encourage family to bring favorite foods.
  • Provide small, frequent meals.
Nutrition

 

 1–Very Poor

Never eats a complete meal. Rarely eats more than one third of any food offered. Eats two servings of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement

OR

Is NPO and/or maintained on clear liquids or IV for more than 5 days.

 All interventions mentioned in 2–Probably Inadequate plus:

  • Perform skin assessment and inspection every shift.

Friction/Shear

Friction and shear are significant risk factors for producing pressure injuries. This category only has three ratings, unlike the other categories that have four ratings, and is rated by whether the client has a problem, potential problem, or no apparent problem in this area. See Table 10.5f for interventions for each level of risk.[10]

Table 10.5f Descriptions and Interventions by Level of Risk for Friction/Shear[11]

Assessment Category Rating Description  Interventions
Friction/Shear

 

 3–No Apparent Problem

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

 Keep bed linens clean, dry, and wrinkle free.
Friction/Shear

 

 2–Potential Problem

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

 All interventions mentioned in 3–No Apparent Problem plus:

  • Avoid massaging pressure points.
  • Apply transparent dressing or elbow/heel protectors to intact skin over elbows and heels.
Friction/Shear

 

 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 maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction.

 All interventions mentioned in 2–Potential Problem plus:

  • Perform skin assessment and inspection every shift.
  • Use a minimum of two people assisting plus a draw sheet in pulling the client up in bed.
  • Keep bed linens clean, dry, and wrinkle free.
  • Apply elbow/heel protectors to intact skin over elbows and heels.
  • Elevate head of bed 30 degrees or less to reduce shear when feasible.

Team Member Roles to Prevent Pressure Injuries

Each member of the health care team has an important role in preventing the development of pressure injuries in at-risk clients. A registered nurse can delegate many interventions for preventing and treating a pressure injury to a licensed practical nurse (LPN) or to unlicensed assistive personnel such as a certified nursing assistant (CNA). See Table 10.5g for an explanation of the role of the RN in preventing pressure injuries, as well as tasks that can be delegated to LPNs and CNAs.

Table 10.5g Team Member Roles in Preventing Pressure Injuries[12]

Role Tasks
RN
  • Conducts or supervises accurate assessment and documentation of head-to-toe skin assessment and pressure injury risk (Braden Scale or Braden Risk Assessment) on admission, daily, and if condition deteriorates (or according to facility policy)
  • Documents care plan tied to identified risk:
    • Sensory perception
    • Moisture
    • Activity
    • Mobility
    • Nutrition
    • Friction/Shear
  • Performs or supervises performance of care plan procedures or treatments
  • Collaborates with other staff to ensure timely and accurate reporting of any skin issues
  • Notifies wound nurse of any skin conditions or high-risk clients
  • Notifies physician of any skin problems
  • Educates client/family about risk factors
LPN
  • Conducts accurate assessment and documentation of head-to-toe skin assessment and pressure injury risk (Braden Scale) on admission, daily, and if condition deteriorates (or according to facility policy)
  • Documents care plan tied to identified risk:
    • Sensory perception
    • Moisture
    • Activity
    • Mobility
    • Nutrition
    • Friction/Shear
  • Performs care for risk as needed
  • Informs RN of any skin issues
CNA
  • Checks skin each time person is turned or cleaned or bed is changed
  • Reports any skin issues to nurse
  • Turns/repositions client as ordered
  • Offers liquids each time in room
  • Keeps skin clean and reapplies protective skin barrier
  • Applies products (lotion, cream, skin sealant, etc.) as needed
  1. This work is derivative of the "Braden Scale" by Prevention Plus. Used under Fair Use. Access for free at https://www.in.gov/core/results.html?collection=global-collection&profile=_default&query=braden+scale ↵
  2. Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html#Tool3B ↵
  3. Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html#Tool3B ↵
  4. Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html#Tool3B ↵
  5. Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html#Tool3B ↵
  6. Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html#Tool3B ↵
  7. Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html#Tool3B ↵
  8. Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html#Tool3B ↵
  9. Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html#Tool3B ↵
  10. Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html#Tool3B ↵
  11. Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html#Tool3B ↵
  12. Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html#Tool3B ↵
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