Braden Scales University of Missouri SWAT Education Presenter

Braden Scales University of Missouri SWAT Education Presenter: Elizabeth Messer, RN BSN CCRN

Braden vs. Braden Q • Both scales contain important subscales of: sensory perception, moisture, activity, mobility, nutrition, and friction & shear. • Braden >=8 years of age; Braden Q < 8 years of age • The modified Braden Q scale has an additional subscale of tissue perfusion & oxygenation • The Braden Q was modified from the adult version of the Braden because the Braden was the most valid and reliable instrument at the time. • There are two critical determinants of pressure ulcers: pressure and tissue tolerance.

Sensory Perception • Braden: the ability to respond meaningfully to pressurerelated discomfort • Braden Q: the ability to respond in a developmentally appropriate way to pressure-related discomfort • The scales are scored the same way from 1 (completely limited) to 4 (no impairment)

Moisture • • • Both scales: degree to which skin is exposed to moisture. Occasionally moist: Braden requiring extra linen change once a day; Braden Q requiring linen change every 12 hours Rarely moist: Braden requiring linen change routinely; Braden Q requiring linen change every 24 hours

Activity • • Both scales score the same from 1 (bedfast) to 4 (walks frequently). Braden Q: Any patient that is too young to ambulate will be given a score of 4.

Mobility • • The ability to change and control body position Both scales scored the same from 1 (completely immobile) to 4 (no limitation)

Nutrition • • • Based on usual food intake pattern Braden Q takes albumin level in to consideration Based on age, developmentally appropriate diet may be completely liquid

Friction & Shear • • Braden scored 1 (Problem) to 3 (No Apparent Problem) Braden Q scored 1 (Significant Problem) to 4 (No Apparent Problem)

Tissue Perfusion & Oxygenation • • • Only on Braden Q Rated from 1 (extremely compromised) to 4 (excellent) Involves MAP, Oxygen saturation, hemoglobin, capillary refill, and serum p. H

University Procedures • • An appropriate Braden score must be documented on admission within 2 hours (with baseline assessment) Document the appropriate scale every 12 hours and with changes Braden score of 18 or less means “at risk” • 17 -18: Low risk • 13 -16: Moderate risk • 10 -12: High risk • <9: Very High risk Braden Q score of 16 or less means “at risk” • No levels of risk. Any score of 16 or less is considered “at risk. ”

Interventions • • Identify low-scoring subscales for targeted interventions. A patient can score quite low in some subscales and normally in other subscales and achieve a normal score on their respective scale.

Interventions…… • SENSORY PERCEPTION • Be the pressure police! Check every line, every time, to make sure the patient’s extremities are not resting on a Foley tube, ECG wires, IV tubing, etc. • Gel packs and extra cushion under bony prominences • Turn schedule • Involve family

Interventions…… • MOISTURE • Use your resources! • Barrier prep, Calazime, Ultrasorb • Discuss moisture control issues with care team

Interventions…… • ACTIVITY • PT/OT consults • Incentives for walking

Interventions…… • MOBILITY • Turn schedules • Position with wedges, pillows, etc • Encourage patient to participate at their level of capability

Interventions…. . • NUTRITION • Set goals • Educate importance of nutrition for wound healing and how to meet goals • Consider dietetics consult

Interventions…… • FRICTION & SHEAR • If spasticity is an issue, consider padding bedrails • Use team lifts • Become familiar with equipment and use it when appropriate (overhead lifts, slings, etc) • Range of motion breaks when in restraints (~Q 2 hours)

Interventions… • TISSUE PERFUSION & OXYGENATION • If position changes are not tolerated, sheet maneuvers can be extremely helpful • Maximize oxygenation with pulmonary toileting and incentive spirometry

Interventions……. • REMEMBER…………………. . • If you don’t chart it, it didn’t happen. • Consults are a service, but nursing ultimately holds the responsibility to appropriately score and intervene on the patient’s behalf.

References Noonan, C. ; Quigley, S. & Curley, M. A. Q. (2011). Using the Braden Q Scale to predict pressure ulcer risk in pediatric patients. Journal of Pediatric Nursing. In Press.