Department: WOUND & SKIN CARE
THE BRADEN SCALE for pressure ulcer risk assessment is used worldwide, but translating those numbers into nursing interventions can be challenging for busy nurses.1 This article describes our color-coded "stoplight" approach to the Braden Scale, and shows how focusing on subcategory scores may be more -important than focusing on the total risk score.
Not just another number
The Braden Scale is a valid and reliable tool for assessing a patient's risk for pressure ulcers, based on deficits in patient mobility, activity, moisture level, nutrition, sensory perception, and friction and shear. Nurses assign numeric scores of 1 to 4 in each category, with the exception of the friction and shear category, where patients are assigned a score of 1 to 3, and then tally the results to gauge pressure ulcer risk. A score of 18 or less indicates risk of pressure ulcer development and the need for escalating interventions.1
But how many times are staff -recording a number in their documentation yet failing to enact interventions to prevent pressure ulcer development? Further, with continuously evolving nursing responsibilities, are basic interventions being lost in the translation?
Our goal was to make the Braden Scale come alive and contain embedded recommendations for care in each of the categories and subcategories. To provide nurses with immediate understanding of their patients' risk of skin breakdown, we used the stoplight color system developed by the Royal Adelaide Hospital in Ade-laide, Australia.2 As the Braden Scale's subscores are listed from low risk (4) to high risk (1), so the colors change with each risk level, from green (low risk) through yellow to red (high risk). Pictures to the left of the scale, adapted from the Royal Adelaide Hospital model, provided an illustration to ensure that clinicians understand which aspect of the patient's condition they're assessing. For a link to the online version of the tool, see References below.
We modified the tool to include subcategory interventions. For exam-ple, suppose you assess Mr. F using the Braden Scale and determine that his total score is 20, broken down as follows: sensory perception, 4; nutrition, 4; activity, 4; mobility, 4; friction and shear, 3; moisture, 1. From the total score, you might assume that Mr. F isn't at risk for a pressure ulcer and requires no intervention. However, the score of 1 for the moisture category means that if Mr. Field's constantly moist skin isn't addressed through appropriate nursing interventions, he could develop a pressure ulcer.
On our "stoplight" version of the Braden Scale, the following interventions are listed for a score of 1 (constantly moist) on the moisture subcategory:
- Provide skin checks at least every 1 to 2 hours.
- Use a perineal cleanser and barrier cream.
- Consider a fecal and/or a urinary management device.
- Ensure appropriate support surfaces for the areas at risk.
Checks and balances
The benefit to our adaptation of the Braden scale is that nurses have a seamless checks-and-balance system for providing care. The adapted tool lets nurses identify risk and immediately see options for appropriate interventions, which can then be selected and documented in the -patient's electronic medical record (EMR). This tool is embedded into the EMR and has been enlarged into poster size for all inpatient areas in our facility.
The need for a well-designed pressure ulcer prevention and treatment program is paramount, especially for facilities without the services of wound, ostomy, and continence nurses. We hope that our adaptation of the Braden Scale can help nurses as they care for patients at risk for pressure ulcers.
1. Braden BJ, Bergstrom N. Clinical utility of the Braden Scale for Predicting Pressure Sore Risk. Decubitus
2. Royal Adelaide Hospital Staff Development Department. Braden pressure ulcer risk assessment: act to prevent pressure ulcers