PRESSURE ULCER RISK ASSESSMENT SCALE
BRADEN ASSESSMENT SCALE
The Braden Scale is a widely used tool for assessing the risk of developing pressure ulcers (PUs) in hospitalized patients. The scale assesses six domains, and each domain has its own point scale. Scores range from 6 (very high risk of developing a PU) to 23 (low risk).
Domain | Description | Score |
---|---|---|
1. Sensory perception | Ability to react to pressure-related stimuli | 1 to 4 points |
Totally limited | 1 point | |
Very limited | 2 points | |
Slightly limited | 3 points | |
No limitations | 4 points | |
2. Humidity | Degree to which the skin is exposed to humidity | 1 to 4 points |
Constantly damp | 1 point | |
Very humid | 2 points | |
Occasionally damp | 3 points | |
Rarely damp | 4 points | |
3. Activity | Level of physical activity | 1 to 4 points |
Lying down | 1 point | |
Limited to the chair | 2 points | |
Walks occasionally | 3 points | |
Walk often | 4 points | |
4. Mobility | Ability to change and control body position | 1 to 4 points |
Completely immobilized | 1 point | |
Very limited | 2 points | |
Slightly limited | 3 points | |
No limitations | 4 points | |
5. Nutrition | Usual pattern of food consumption | 1 to 4 points |
Very weak | 1 point | |
Probably unsuitable | 2 points | |
Suitable | 3 points | |
Excellent | 4 points | |
6. Friction and cutting | Ability of the skin to resist wear and tear and injury due to movement | 1 to 3 points |
Significant problem | 1 point | |
Potential problem | 2 points | |
No apparent problem | 3 points |
Interpretation of the total score:
- Very high risk: 6-9 points
- High risk: 10-12 points
- Moderate risk: 13-14 points
- Low risk: 15-18 points
- Very low risk: 19-23 points
Remember that the interpretation of the score may vary depending on the institution or the literature. Clinical assessment and the judgment of the healthcare professional are fundamental when using this tool.
- Foam: They are the most common and most affordable. The high-density foam distributes the body's weight evenly, reducing pressure points.
- Alternating air: These are inflatable mattresses made up of several cells that inflate and deflate alternately. This allows for regular redistribution of pressure. They are particularly suitable for people at high risk of bedsores.
- Water or Gel: They help distribute pressure and are cool, which can be beneficial for those who perspire a lot.
A - Grade 0 - Leather in good condition.
B - Grade 1 - Non-blanchable erythema.
C - Grade 2 - Partial loss of skin thickness.
D - Grade 3 - Total loss of skin thickness.
E - Grade 4 - Total loss of tissue thickness.
- Waterproof coating: Essential for preventing liquids from entering and making cleaning easier.
- Antibacterial: Reduces the risk of infection at the site of bedsores.
- Temperature regulation: Helps keep skin cool and prevent excessive perspiration.