Please review the following educational documents
Predicting Pressure Sore Risk (November 2011)
The Braden Scale for Predicting Pressure Sore Risk was developed by Barbara Braden and Nancy Bergstrom.
The Braden Scale for Predicting Pressure Sore Risk is a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure ulcers. It measures functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure. Lower levels of functioning indicate higher levels of risk for pressure ulcer development.
The Braden Scale is a summated rating scale made up of six subscales scored from 1-4 (1 for low level of functioning and 4 for the highest level or no impairment). Total scores range from 6-23 (one subscale is scored with values of 1-3, only). The subscales measure functional capabilities of the patient that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure. A lower Braden Scale Score indicates lower levels of functioning and, therefore, higher levels of risk for pressure ulcer development.
The Braden Scale is used by nurses and other health care providers. We had the risk scoring tool - Braden Scale in Centricity and now have the Braden Scale in Epic too. There are other types of risk scoring tools like the Norton. (The Braden is the most widely used).Based off of the scoring that a patient receives from the Braden Scale, the next appendix in the policy addresses specific interventions that can be followed based on each subscale. The six subscales are sensory, perception, moisture, activity, mobility, nutrition and friction or shear. The interventions the care team should be providing for the patient are dependent on the subscale of those categories. The lower the score, the more detailed the interventions become. Epic will have the capability of showing a prompt to the nurse as she or he documents the Braden score, and it prompts if a pressure ulcer prevention bundle needs to be instituted as the nurse inputs the Braden score and if the score is low. The pressure ulcer bundle aligns with the same interventions that the Braden Scale interventions recommend for pressure ulcer prevention.