Braden Scale Summary

Braden Scale Notes

Overview of Braden Scale

• Purpose: The Braden Scale is utilized to assess skin integrity and predict the risk of pressure ulcers.

  • Components Assessed:

  • Mental Status

  • Continence

  • Mobility

  • Activity

  • Nutrition

Scoring System

• Numerical Scores Assigned:

  • 19-23: No Risk

  • 15-18: Mild Risk

  • 13-14: Moderate Risk

  • 10-12: High Risk

  • 9 or below: Very High Risk

• Caution: The Braden Scale has been noted to potentially overpredict pressure injury risk.

Components of the Braden Scale

1. Sensory Perception

• Definition: Ability to respond meaningfully to pressure-related discomfort.

  • Levels:

  • Completely Limited

  • Very Limited

  • Slightly Limited

  • No Impairment

2. Moisture

• Definition: Degree to which skin is exposed to moisture.

  • Levels:

  • Constantly Moist

  • Very Moist

  • Occasionally Moist

  • Rarely Moist

3. Activity

• Definition: Degree of physical activity.

  • Levels:

  • Bedfast

  • Chairfast

  • Walks Occasionally

  • Walks Frequently

4. Mobility

• Definition: Ability to change and control body position.

  • Levels:

  • Completely Immobile

  • Very Limited

  • Slightly Limited

  • No Limitation

5. Nutrition

• Definition: Usual food intake pattern.

  • Levels:

  • Very Poor

  • Probably Inadequate

  • Adequate

  • Excellent

6. Friction and Shear

• Definition: Impact of friction and shear forces on skin integrity.

  • Levels:

  • Problem

  • Potential Problem

  • No Apparent Problem

Conclusion

• Proper use of the Braden Scale can aid in assessing patients' risk for pressure ulcers, thereby guiding preventative care strategies effectively.

• Regular assessment and updates to care plans based on Braden Scale scores is recommended for optimal patient skin management.