The Braden Scale for Predicting Pressure Ulcer Risk, is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstrom. The purpose of the scale is to help health professionals, especially nurses, assess a patient's risk of developing a

pressure ulcer Pressure ulcers, also known as pressure sores, bed sores or pressure injuries, are localised damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combi ...

Assessment using the Braden Scale

The Braden scale assesses a patient's risk of developing a pressure ulcer by examining six criteria:

Sensory perception

This parameter measures a patient's ability to detect and respond to discomfort or pain that is related to pressure on parts of their body. The ability to sense pain itself plays into this category, as does the level of consciousness of a patient and therefore their ability to cognitively react to pressure-related discomfort.

Moisture

Excessive and continuous skin moisture can pose a risk to compromise the integrity of the skin by causing the skin tissue to become macerated and therefore be at risk for

epidermal The epidermis is the outermost of the three layers that comprise the skin, the inner layers being the dermis and hypodermis. The epidermis layer provides a barrier to infection from environmental pathogens and regulates the amount of water relea ...

erosion. So this category assesses the degree of moisture the skin is exposed to.

Activity

This category looks at a patient's level of physical activity since very little or no activity can encourage atrophy of muscles and breakdown of tissue.

Mobility

This category looks at the capability of a patient to adjust their body position independently. This assesses the physical competency to move and can involve the clients willingness to move.

Nutrition

The assessment of a client's nutritional status looks at their normal patterns of daily

nutrition Nutrition is the biochemical and physiological process by which an organism uses food to support its life. It provides organisms with nutrients, which can be metabolized to create energy and chemical structures. Failure to obtain sufficient n ...

. Eating only portions of meals or having imbalanced nutrition can indicate a high risk in this category.

Friction and Shear

Friction and shear looks at the amount of assistance a client needs to move and the degree of sliding on beds or chairs that they experience. This category is assessed because the sliding motion can cause shear which means the skin and bone are moving in opposite directions causing breakdown of cell membranes and

capillaries A capillary is a small blood vessel from 5 to 10 micrometres (μm) in diameter. Capillaries are composed of only the tunica intima, consisting of a thin wall of simple squamous endothelial cells. They are the smallest blood vessels in the body: ...

. Moisture enhances the susceptibility of friction.

Scoring with the Braden Scale

Each category is rated on a scale of 1 to 4, excluding the 'friction and shear' category which is rated on a 1-3 scale. This combines for a possible total of 23 points, with a higher score meaning a lower risk of developing a pressure ulcer and vice versa. A score of 23 means there is no risk for developing a pressure ulcer while the lowest possible score of 6 points represents the severest risk for developing a pressure ulcer. The Braden Scale assessment score scale: *Very High Risk: Total Score 9 or less *High Risk: Total Score 10-12 *Moderate Risk: Total Score 13-14 *Mild Risk: Total Score 15-18 *No Risk: Total Score 19-23

References

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External links

Braden Scale Official WebsiteBraden Scale Instruction sheetBraden Scale Assessment form
Nursing Medical scales