Apart from friction, there are several factors that can put a patient at risk of developing pressure injuries. Factors such as increased moisture, increased sensory perception, inadequate nutrition, impaired mobility, and reduced activity are just some of them.
That being said, it’s crucial to be able to anticipate, if not predict, if a patient has the potential of developing such. The good news is there is a way to tell if patients are at risk of developing pressure injuries and that is made possible through the Braden Scale.
What is the Braden Scale?
The Braden Scale is an assessment tool made up of six subscales, each designed to measure risk elements that can contribute to the duration or intensity of pressure or the lower tissue’s tolerance for pressure, for that matter.
The tool was designed to promote early detection and identification of patients at risk of developing pressure injuries.
The six subscales are as follows:
Activity - pertains to the degree of physical activity
Mobility - the ability to change and control body position
Moisture - the degree to which any skin is exposed to fluid
Nutrition - pertains to the patient’s usual food intake pattern
Shear and Friction - refers to the ability to maintain posture and/or move in a chair or bed by lifting completely off a surface without dragging
Sensory Perception - the ability to respond meaningfully to pressure-related discomfort
Each of these subscales are given scores between 1 to 4, with each score being accompanied by a descriptor. The lower the total score is, the higher the risk for the patient.
The scores from these subscales are added, the total score indicating the patient’s risk based on the following ranges:
Mild risk: 15-18
Moderate risk: 13-14
High risk: 10-12
Severe risk: less than 9
The Braden Scale was also developed to help review and analyze contributing factors as well as discuss possible interventions that will help prevent pressure injuries.
Common Locations
Pressure injuries are usually found in the following locations:
Back of the head
Shoulder blade
Lower back
Elbow
Hip
Sacrum
Heel
Intervention and Prevention
Given the nature of pressure injuries, it’s extremely important for patients to undergo routine skin inspections and assessments as well as timely reporting of any changes in the skin.
Consulting dieticians is also recommended so nutritional deficits for caloric and protein needs, along with vitamin supplementation, can be checked. Equally important is proper hydration to keep the skin from getting dry.
For moisture, consider barrier ointments and creams as well as absorbent pads. Toileting schedules are also recommended.
As for friction and shear, the head of the bed should not be above a 30-degree angle except when the patient is eating.
Lastly, it’s crucial to establish protocols and to come up with individualized plans of care so you can maximize outcome potential and achieve positive results.
Final Thoughts
Pressure injuries can be very painful and discomforting and though there are medications available for pain management, prevention will still be better than cure especially in cases like this. The Braden Scale makes this possible, making it an all important tool someone in the wound care industry should be aware of.