Wagner Scale + Braden Scale (Wound Grading)

what is the purpose of the WAGNER SCALE

to classify depth + presence of infection in wounds of arterial origin

what type of WOUNDS does the WAGNER SCALE evaluate

diabetic foot ulcers

what does GRADE 0 on the WAGNER SCALE indicate

pre-ulcerative lesions, healed ulcers, presence of bony deformity

what does GRADE 1 on the WAGNER SCALE indicate

superficial ulcer without subcutaneous tissue involvement

what does GRADE 2 on the WAGNER SCALE indicate

penetration through subcutaneous tissue; may expose bone, tendon, ligament or joint capsule

what does GRADE 3 on the WAGNER SCALE indicate

osteitis, abscess or osteomyelitis

what does GRADE 4 on the WAGNER SCALE indicate

gangrene of digit

what does GRADE 5 on the WAGNER SCALE indicate

gangrene of foot requiring disarticulation

what is the purpose of the BRADEN SCALE

to determine potential risk for developing pressure ulcers

what type of WOUNDS does the BRADEN SCALE evaluate

pressure ulcers

what are the 6 ITEMS of the BRADEN SCALE

1. sensory perception

2. moisture

3. activity

4. mobility

5. nutrition

6. friction + shear

what is assessed during evaluation of SENSORY PERCEPTION (3)

1. patients ability to sense discomfort + pain

2. allows patient to communicate pain + discomfort

3. neuropathy + paralysis

how many total points are involved in SENSORY PERCEPTION

4 points

what is evaluated during the assessment of MOISTURE

patients exposure to moisture such as wound drainage, urine, stool, sweat, etc

how many total points are involved in MOISTURE

4 points

what is assessed during the evaluation of ACTIVITY

patient's ability to position change + move their body with or without use of aids

how many total points is involved in ACTIVITY

4 points

what is assessed during the evaluation of MOBILITY

patients ability to move their body while laying down + sitting

how many total points are involved in MOBILITY

4 points

what is assessed in evaluation of NUTRITION

patient's nutritional intake

how many total points are involved in NUTRITION

4 points

what is assessed during the evaluation of FRICTION + SHEAR

patient's muscle strength + ability to maintain positioning in a bed or chair; skin sliding

how many total points are involved in FRICTION + SHEAR

3 points

what are the SCORE RANGES for BRADEN SCALE

1. higher total score least likely to develop pressure ulcers

2. lower total score higher risk to develop pressure ulcers

what does a total score of 19-23 indicate

19-23: NO RISK of developing pressure ulcers

what does a total score of 15-18 indicate

15-18: MILD RISK of developing pressure ulcers

what does a total score of 13-14 indicate

13-14: MODERATE RISK of developing pressure ulcers

what does a total score of 10-12 indicate

10-12: HIGH RISK of developing pressure ulcers

what does a total score of <9 indicate

<9: SEVERE RISK of developing pressure ulcers