The study setting was a bed acute care facility in the Midwestern United States. Methods: A retrospective review of 20 patient charts was conducted.
Data were collected both before and after pressure ulcer occurrence. A resident with paraplegia who is experiencing loss of sensation to the lower half of the body would automatically score only a 2 because of loss of sensation over half of the body.
A resident with diabetes with some neuropathy in the feet would automatically score a 3 if they cannot feel pain or discomfort in one or more of their extremities. Monofilament testing is a fairly inexpensive, accurate test that is used to assess for loss of protective sensation or sensory impairment.
A trained professional can usually complete the test fairly quickly and can document or report a positive or negative test result, indicating the presence or absence of peripheral neuropathy. These residents are in the hospital, scooting up in bed, spending more time in bed, possibly wheelchair bound, with multiple pre-existing comorbidities and usually one or more deficits. It is possible to score a 4 here, but again, it is rare. The takeaway point here for sensory perception is to assess for neuropathy, SCI, and dementia.
These residents may often be deficient in this specific category. It is important to understand the category and definitions to score the resident accurately. Education with nursing staff is pertinent here, and pocket cards are always helpful. Yearly competencies for long-term care staff on Braden Scale education are also helpful, along with orientation for new nurses, to be sure that the information is understood. Education by a certified wound, ostomy, and continence nurse, continued support, and follow-up are needed to ensure accurate Braden Scale scores within any facility.
Up next: The Braden Scale category Moisture. Note: For anyone who wishes to utilize the Braden Scale in their health care facility, you must request permission to do so. Please visit www. About the Author Holly is a board certified gerontological nurse and advanced practice wound, ostomy, and continence nurse coordinator at The Department of Veterans Affairs Medical Center in Cleveland, Ohio.
She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately six years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention.
She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation. She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible.
She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes. The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc.
Moves feebly or requires minimal assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices.
Maintains a relatively good position in a chair or bed most of the time but occasionally slides down. All interventions mentioned in 3—No Apparent Problem plus:. Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction. All interventions mentioned in 2—Potential Problem plus:.
Each member of the health care team has an important role in preventing the development of pressure injuries in at-risk patients. A registered nurse can delegate many interventions for preventing and treating a pressure injury to a licensed practical nurse LPN or to unlicensed assistive personnel such as a certified nursing assistant CNA.
Skip to content Several factors place a patient at risk for developing a pressure injury, in addition to shear and friction. Sensory Perception The sensory perception risk factor is defined as the ability to respond meaningfully to pressure-related discomfort. Sensory Perception 3—Slightly Limited Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR Has some sensory impairment that limits ability to feel pain or discomfort in 1 or 2 extremities.
Sensory Perception 2—Very Limited Responds only to painful stimuli. OR Has a sensory impairment that limits the ability to feel pain or discomfort over half of the body. All interventions mentioned in 3—Slightly Limited plus: Consider specialty mattress or bed. Sensory Perception 1—Completely Limited Unresponsive does not moan, flinch, or grasp to painful stimuli, due to diminished level of consciousness or sedation. OR Limited ability to feel pain over most of the body.
All interventions mentioned in 2—Very Limited plus: Use pillows between knees and bony prominences to avoid direct contact. Moisture The moisture risk factor is defined as the degree to which skin is exposed to moisture.
Moisture 3—Occasionally Moist Skin is occasionally moist, requiring an extra linen change approximately once per day. All interventions mentioned in 4—Rarely Moist plus: Use moisture barrier ointments protective skin barriers. Moisturize dry unbroken skin. Avoid hot water.
Use mild soap and soft cloths or packaged cleanser wipes. Routinely check incontinence pads. Avoid use of diapers but if necessary, check frequently every hours and change as needed. If stool incontinence, consider bowel training and toileting after meals. Moisture 2—Often Moist Skin is often but not always moist. All interventions mentioned in 3—Occasionally Moist plus: Check incontinence pads frequently every hours.
Consider a low air loss bed. Moisture 1—Constantly Moist Skin is kept moist almost constantly by perspiration, urine, etc. All interventions mentioned in 2—Often Moist plus: Assess and inspect skin every shift. Check incontinence pads frequently every hours and change as needed. Apply condom catheter if appropriate. If stool incontinence, consider bowel training and toileting after meals or rectal tubes if appropriate.
Activity The activity risk factor is defined as the degree of physical activity. Activity 3—Walks Occasionally Walks occasionally during the day, but for very short distances, with or without assistance. Activity 2—Chair fast Ability to walk is severely limited or nonexistent. Activity 1—Bedfast Confined to bed. This work is derivative of the "Braden Scale" by Prevention Plus.
Used under Fair Use. Preventing pressure ulcers in hospitals. Previous: Next: Share This Book Share on Twitter. Occasionally refuses a meal, but will take a supplement if offered OR Is on a tube feeding or TPN regimen that most likely meets most of nutritional needs.
Observe and monitor nutritional intake. Occasionally will take a dairy supplement OR Receives less than optimum amount of liquid diet or tube feeding. All interventions mentioned in 3—Adequate plus: Encourage fluid intake as appropriate.
Offer nutrition supplements and water. Encourage family to bring favorite foods. Provide small, frequent meals. All interventions mentioned in 2—Probably Inadequate plus: Perform skin assessment and inspection every shift.
All interventions mentioned in 3—No Apparent Problem plus: Avoid massaging pressure points. All interventions mentioned in 2—Potential Problem plus: Perform skin assessment and inspection every shift. Use a minimum of two people assisting plus a draw sheet in pulling the patient up in bed.
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