Measurement of the risk of pressure ulcer through a validated scale.
Objective:
To quantify the patient’s risk of pressure ulcer occurrence.
Equipment:
Braden pressure ulcer risk assessment scale.
Material:
– Nursing records.
Procedure:
– Preserve the patient’s privacy.
– Inform the patient.
– Request the collaboration of the patient and family.
– Assess the patient’s risk of pressure ulcer using the Braden scale.
– Record in the nursing documentation: score obtained through the patient’s risk assessment, date and time.
– Braden Scale
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SENSORY PERCEPTION Ability to react to pressure-related discomfort |
1.- Completely limited Having a decreased level of consciousness or being sedated, the patient does not react to painful stimuli (moaning, flinching or grasping), or limited ability to feel pain in most parts of his body. |
2.- Very limited Reacts only to painful stimuli. Cannot communicate discomfort except by moaning or agitation, or has a sensory deficit that limits the ability to perceive pain or discomfort in more than half of the body. |
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EXPOSURE TO HUMIDITY Level of skin exposure to moisture |
1.- Constantly moist The skin is constantly exposed to moisture from: perspiration, urine, etc. Moisture is detected every time the patient is moved or turned. |
2.- Occasionally moist The skin is often, but not always, damp. Bedding should be changed at least once per shift. |
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ACTIVITY Level of Physical activity |
1.- Bedridden Patient constantly bedridden. |
2.- In chair Patient unable to walk or with very limited deam- bulation. Cannot support his own weight and needs help to transfer to a chair or wheelchair. |
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MOBILITY Ability to change and control the position of the body. |
1.- Completely immobile Unassisted cannot make any change in body or limb position. |
2.- Very limited Occasionally makes slight changes in body or limb position, but is unable to make frequent or significant changes on his/her own. |
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NUTRITION Usual pattern of food intake |
1.- Very poor Never eats a full meal. Rarely takes more than one third of any food offered. Daily eats two services or less with protein intake (meat or dairy products). Drinks few liquids. Does not take liquid dietary supplements or is fasting and on liquid diet or sera for more than five days. |
2.-Probably inadequate Rarely eats a full meal and usually eats only half of the food offered. Protein intake includes only three servings of meat or dairy products per day. Occasionally takes a dietary supplement, or receives less than the optimal amount from a liquid or nasogastric tube diet. |
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RICE AND DANGER OF SKIN LESIONS |
1.- Problem Requires moderate to maximum assistance to be moved. Impossible to lift completely without slipping between the sheets. Frequently slides down in bed or in a chair, requiring frequent repositioning with maximum assistance. The existence of spasticity, contractures or agitation produce an almost constant rubbing. |
Potential problem Moves very weakly or requires minimal assistance. During movements, the skin probably rubs against part of the sheets, chair, restraints or other objects. Most of the time maintains a relatively good position in the chair or bed, although occasionally may slip downward. |
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3.- Slightly limited Reacts to verbal commands but cannot always communicate discomfort or the need to be repositioned or presents some sensory difficulty that limits his ability to feel pain or discomfort in at least one extremity. |
4.- No limitations Responds to verbal commands. No sensory deficits that may limit his ability to express or feel pain or discomfort. |
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3.- Occasionally moist The skin is occasionally damp, requiring a supplemental change of bedding approximately once a day. |
4.- Rarely moist Skin is generally dry. Bedding is changed according to set intervals for routine changes. |
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3.- Occasionally wanders Occasionally wanders with or without assistance, during the day, but for very short distances. Spends most of the daytime hours in bed or in a chair. |
4.- Frequently wanders Wanders outside the room at least twice a day and inside the room at least two hours during wandering hours. |
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3.- Slightly limited Frequently makes slight changes in body or limb position on his/her own. |
4.- Unrestricted Frequently performs major position changes without assistance. |
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3.- Adequate Eats more than half of most meals. Eats a total of four servings per day of protein (meat or dairy products). Occasionally may refuse a meal but will take a dietary supplement if offered, or receives nasogastric tube or parenteral nutrition covering most of his nutritional needs. |
4.- Excellent Eats most of each meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require dietary supplements. |
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No apparent problem She moves in bed and chair independently and has sufficient muscle strength to get up fully when moving. At all times maintains a good position in bed or chair. |
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