Description of the Categories of the Braden Risk Assessment Scale

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Description of the Categories of the Braden Risk
Assessment Scale
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6 sub-categories

• Sensory perception
• mobility
• activity
• nutrition
• friction/shear
• moisture

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Process

• Evaluate the patients condition within each
  category
• Assign a rating number for each
• Add all together to develop a rating score (may
  range from 6 - 23)
• Lower the score the higher the risk of pressure
  ulcer development

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Sensory Perception

• Measures ability to perceive discomfort in a
  meaningful way - may be by movement,
  communication or some other action that alerts
  the caregiver
• The discomfort cues the patient to move self, to
  ask for help and/or express discomfort
• Has 2 levels of potential responses
• patient with decreased conscious state
• patient with decreased cutaneous sensation
• if patient has impairment in both assign the
  LOWER of possible categories

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Decreased Level of Consciousness

• Completely (Coma) test for response
• cannot respond to painful stimuli - no moaning
  flinchinggrasping. Only has reflex responses
  present - flexion/extension
• do not test using the fingers/toes or nail beds -
  may stimulate a primitive stimuli
• Very
• unconscious, doesnt respond to verbal
  stimuli/commands. Does flinch or moan with
  painful stimuli
• Slightly Limited
• responds to verbal commands, may not open eyes
• person may be over (heavily) sedated

6
Diminished cutaneous sensation

• Deficits usually associated with neurological
  disease that involves paralysis
• Completely
• cannot feel pain over most of the body -
  Quadraplegia
• Very
• person cannot feel pain over 1/2 of the body -
  para/hemiplegia
• Slight
• lack of ability to feel pain in 1 or 2
  extremities - peripheral neuropathy/chronic
  vascular disease/ neurological diseases/ MS
• No impairment
• Fully alert or nearly so has the ABILITY to feel
  pain - no paralysis or parasthesis

7
Moisture

• Degree to which skin is exposed to moisture. May
  be associated with urine/ faeces/perspiration/woun
  d drainage
• Constantly
• moist nearly all the time - e.g constant
  dribbling perspire excessively or other
  neurological problems affecting the autonomic
  system
• Very
• periods of dryness (2 - 3 hrs)between episodes.
• Occasionally
• daily but infrequent exposure - e.g. night
  incontinence use of padding systems, use of
  moist packs that soak into surrounding skin

8
Activity

• Measures frequency of ambulation
• Bedfast
• not even able to sit in chair/side of bed x1
  daily.
• Chairfast
• able to stand/walk only a little or not at all.
  Either sits or lies
• walking limited to 1-2 steps . Also
  para/quadraplegic
• Walks occasionally
• walks 2 or more times a day but only for very
  short periods -few steps to bathroom and back to
  bed
• Walks frequently
• may walk outside or round room - moderate
  distance every hour or 2

9
Mobility

• Assesses persons mobility in bed - a person may
  be in bed but at little risk if able to shift
  position
• Mobility in bed refers to not only the ability to
  change position but also their motivation to
  change and sustain changes in position
• Assessment shouldnt take into account
  repositioning regimes - are not relevant when
  determining degree of risk
• Do consider the patients ability to make slight
  position changes - small changes made frequently
  are as effective as gross changes

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Mobility Categories

• Completely
• cant independently make changes in position at
  all without assistance, left without help makes
  ineffectual movements
• Very
• occasional position changes but may not be able
  to maintain a new position, ability to change
  position inadequate or ineffectual or strong
  preference for 1 position - effects of
  sedation/depression
• Slightly
• can shift slightly or often, needs help to
  maintain or attain change
• No - frequent and major changes without help or
  reminder

11
Nutrition

• Assessment reflects USUAL intake not temporary
  status
• 2 layers of potential responses
• oral
• IV/TPN/Enteral/liquid supplements
• will review each separately

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Oral

• Very poor
• diet well below requirements, rarely eats more
  than 1/3 meals eaten. Doesnt accept a supplement
• Probably Inadequate
• small portions sporadically, diet marginal,
  rarely eats a complete meal
• occasional liquid supplements - drinks small
  amount
• Adequate
• occasionally may need encouragement to complete a
  meal, may refuse a meal, usually takes a
  supplement
• Excellent - eating adequately, doesnt require
  supplements

13
IV/TPN/Enteric/Supplements

• Very Poor
• standard IV or clear fluids
• Nil Orally for 5 days
• poor intake before IVs/clear liquids was
  commenced
• Probably Inadequate
• sole source is liquid supplements takes less
  than is recommended by the manufacturer
• Adequate
• full regime of tube feeding/TPN
• Excellent

14
Friction/Shear - force applied to skin surface

• Problem
• requires moderate/maximum assistance moving in
  bed/chair, cannot be lifted off the surface
  completely -skin slides vs the sheet, insult is
  repeated often
• Exposed to constant friction due to
  agitation/contractures/spasticity
• Potential Problem
• some exposure to friction/shear can move in bed,
  requires some help skin probably slides across
  sheet.
• Use of restraints, casts, prostheses.
  Occasionally slides down bed/chair
• No apparent problem
• has enough muscle strength to lift up
• maintains good position in chair without sliding
  down

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CALCULATION OF RISK

• Add sub-category scores together
• Identify equipment product type needed to support
  level of risk.
• Note
• Whilst overall score determines equipment type
  you must put preventative care strategies in
  place against each risk factor identified and
  monitor effectiveness.