Braden policy

LAKEWOOD HEALTH SYSTEMSUBJECT: Braden Scale for Predicting Pressure SoreSOURCE:REVIEWED: 5-2008Nursing StandardsLabel9 or less = Very High Risk 10-12 = High RiskDATE OF13-14 = Moderate Risk 15-18 = Mild RiskASSESSMENTRISK FACTOR SCORE / DESCRIPTION 1 2 3 4SENSORYPERCEPTIONability to respondmeaningfully to pressurerelateddiscomfort1. Completely limitedUnresponsive (does notmoan, flinch or grasp) topainful stimuli, due todiminished level ofconsciousness or sedation,or has limited ability to feelpain over most of bodysurface.2. Very LimitedResponds only to painfulstimuli. Cannot communicatediscomfort except by moaningor restlessness or has somesensory impairment whichlimits ability to feel pain ordiscomfort over 1/2 of body.3. Slightly limitedResponds to verbalcommands, but cannotalways communicatediscomfort or need to beturned, or has some sensoryimpairment which limitsability to feel pain ordiscomfort in one or twoextremities.4. No ImpairmentResponds to verbalcommands. Has no sensorydeficit which would limitability to voice pain ordiscomfort.MOISTUREdegree to which skin isexposed to moisture1. Constantly Moist Skinis kept moist almost alwaysby perspiration, urine, etc.Dampness is detected everytime patient is moved orturned.2. Often MoistSkin is often but not alwaysmoist. Linen must bechanged at least once a shift.3. Occasionally MoistSkin is occasionally moist,requiring an extra linenchange about once a day4. Rarely MoistSkin is usually dry, requiringlinen change only at routineintervals.ACTIVITYdegree of physical activity1. Bedfast Confined to bed 2. ChairfastAbility to walk severely limitedor non-existent. Cannot bearown weight and/or must beassisted into chair orwheelchair3. Walks occasionallyWalks occasionally duringday but for very shortdistances, with or withoutassistance. Spends most ofeach shift in bed or chair4. Walks frequentlyWalks outside the room atleast twice a day and insideroom at least once every twohours during waking hoursMOBILITYability to change andcontrol body position1. Completely ImmobileDoes not make even slightchanges in body orextremity position withoutassistance.2. Very limitedMakes occasional slightchanges in body or extremityposition but unable to makefrequent or significantchanges independently.3. Slightly limitedMakes frequent though slightchanges in body or extremityposition independently.4. No limitationsMakes major and frequentchanges in position withoutassistance.NUTRITIONusual food intake patternFRICTION & SHEARTOTAL SCORE1. Very PoorNever eats a completemeal. Rarely eats morethan 1/3 of any food offered.Eats 2 servings of protein(meat and dairy products)per day. Takes fluids poorly.Does not take a liquiddietary supplement or isNPO and/or maintained onclear liquids or IVs for morethan five days.1. Problem Requiresmoderate to maximumassistance in moving.Complete lifting withoutsliding against sheets isimpossible. Frequentlyslides down in bed or chair,requiring frequentrepositioning with maximumassistance. Spasticity,contractures, or agitationleads to almost constantfriction.2. Probably InadequateRarely eats a complete mealand generally eats only about1/2 of any food offered.Protein intake includes only 3servings of meat or dairyproducts per day.Occasionally will take adietary supplement, orreceives less than optimumamount of liquid diet or tubefeeding.2. Potential problems Movesfeebly or requires minimumassistance. During a moveskin probably slides to someextent against sheets, chair,restraints or other devices.Maintains relatively goodposition in bed or chair mostof the time but occasionallyslides down.3. AdequateEats over half of mostmeals. Eats a total of 4servings of protein (meatand dairy products) eachday. Occasionally will refusea meal, but will take asupplement if offered, or ison tube feeding or TPNregimen, which probablymeets most of nutritionalneeds.3. No apparent problemMoves in bed and in chairindependently and hassufficient muscle strength tolift up completely duringmove. Maintains goodposition in bed or chair at alltimes.Refer to Skin Safety PolicyASSESS. DATE EVALUATOR SIGNATURE ASSESS. DATE4. ExcellentEats most of every meal.Never refuses a meal.Usually eats a total of 4 ormore serving of meat anddairy products. Occasionallyeats between meals. Doesnot require supplementation.1 / / 3 / /2 / / 4 / /© Copyright Barbara Braden and Nancy Bergstrom, 1988 All rights reservedAdditional Risk assessments:1. Individual able to shift weight in chair orbed independently?Yes No (begin Tissue Tolerance assessment**Care Center Only)2. Individual experiencing acute illness?Yes No**(Increase risk level by one if individual has fever,albumin or pre-albumin or has a diastolic BP < 60.)3. Individual has chronic or terminal illness?Yes No4. Previous history of pressure damage?Yes No5. Extreme age consideration? (80)Yes No6. Medication? – Chemotherapy, Psychotropic, or steroid use?Yes No7. Consider an Nutritional Lab Levels (Albumin, Pre-Albuminand HGB)Braden Checklist.doc

Nsg Diagnosis: Potential for impaired skin integrity as evidenced by Braden Score = 300#, consider a bariatric bedFree-float heels by elevating calveson pillows – keeping heels free of allsurfaces / Use Heel bootElbow protectors as indicatedMinimize/eliminate pressure frommedical devices - assess Q shiftReferral to WOC nurse if total score is12 or lessGoal: Eliminate Friction / ShearTTT - Tissue Tolerance Testing (if unableto or non-compliant w/ shifting weightindependently) **Care Center OnlyInitiate Stage I protocol as directed by TTEncourage individual to make frequentsmall position changesUse pillow or wedges to reducepressure on bony prominencesAt a MINIMUM – turn every 2 hoursPT/OT consultsAssist w/ PROMInterventionsUtilize transfer or assistive devices to reduce friction / shearUse lift sheets or devices to turn, reposition or transfer patientsMaintain HOB at or below 30 degrees or lowest possible level of elevation base on medical condition of individual.Match knee angle with angle of the HOBKeep skin clean and dryUse trapeze for assist in repositioning when not contraindicatedPT/OT consultsConsider non-slip surface for bed or W/C to decrease shearGoal: 1) Manage/reduce moisture against skin 2) Protect intact skinInterventionsImplement toileting schedule as appropriateCleanse skin gently w/ pH-balanced cleansers, dry well and apply moisture barrier w/ each incontinent episodeUse Pro-shield Plus on Intact skin.EPC Zinc oxide ointment on red, irritated skin. If no effect obtain referral to WOC nurse.Contain urine and stool. Only use chux/diapers/ pads when appropriateCommunicate incontinent episodes to primary care nurseContain wound drainage – consider Wound / Ostomy nurse referral.Keep skin folds dryGoal: 1) Improve/maintain Nutrition / Hydration 2) Protect intact skinInterventionsProvide nutrition compatible w/ individual choices/wishes and medical conditionAlert the staff when hydration has been withheld (i.e.-NPO) and intervene with food / fluids when restriction is liftedDietary consult if Score 18 or less. Consider order for nutritional values – HGB, Albumin, and PreAlbumin.Advance diet and provide / encourage intake of supplement & fluids as medically indicated.TTT - Tissue Tolerance Testing (if unable to ornon-compliant w/ shifting weightindependently) **Care Center OnlyInitiate Stage I protocol as directed by TTTEncourage individual to weight shift every 15minutesReposition every 1 hour if patient unable toreposition self as directed by TTTPT/OT consultsAssist w/ PROMUtilize pressure re-distribution cushion whilesittingOther InterventionsPrimary Nurse to complete a DAILY Braden of all IP, ICU, OP 24 hour stay, SW & BHU patients. Care Center residents - Weekly x4 wks and then quarterly.Comprehensive skin assessment by RN at admit, then daily skin inspection by primary nurse on IP, ICU, OP 24 hour stay, SW and BHU patients and weekly on SW, Care Center and HomeCare patients.Braden Checklist.doc