Determining the Patient’s Pressure Ulcer Risk:  Performing an Assessment

Nurses use a special scale to evaluate the patient’s pressure ulcer risk.  The most common is called the Braden Scale for Predicting Pressure Sore Risk©. The Braden Scale is the most preferred tool to use for assessing risk of pressure ulcers (this copyrighted tool is available at http://www.bradenscale.com.braden.pdf). It consists of six categories: sensory perception (how the patient responds to pressure-related discomfort), moisture (how exposed skin is to moisture), activity (how physically active the patient is), mobility (whether the patient can change and control body position), nutrition (what the patient normally eats), and friction/shear. The total score can range from 6 to 23 with a lower score indicating a higher risk. Patients with a Braden Scale score below 18 [or a low score on any subscale] require intervention and the care team should be consulted. The level of risk dictates the intervention strategies that should be used.

At risk (Braden score 15 – 18)

• Turn the patient on a regular schedule.
• Help the patient be as active as possible (e.g., walk or get up from bed).
• Protect the patient’s heels.
• Use pressure-redistribution surfaces.
• Manage moisture, nutrition, friction, and shear.
• Advance to a higher level of risk if other major risk factors are present.
  

Moderate risk (Braden score 13 – 14)

• Use same protocol as for ‘at risk’ patients.
• Position patient at 30° lateral incline using foam wedges.
  

High risk (Braden score 10 – 12)

• Use same protocol as for ‘moderate risk’ patients.
• In addition to turning the patient on a regular schedule, make small shifts in their position.
  

Very high risk (Braden score = 9)

• Use same protocol as for ‘high risk’ patients.
• Add a pressure-redistribution surface (e.g., low-air-loss bed) for patients with severe pain or with additional risk factors (e.g., immobility, malnutrition).
  

It is very important to make sure patients who are at risk of pressure ulcers are receiving proper nutrition. If there are any questions or concerns about nutrition, a dietitian should be consulted.  When patients are at risk of pressure ulcers, bony areas should not be massaged and donut-type pillows should never be used. It is also important to make sure the patient is receiving plenty of fluid (unless otherwise directed) and that the skin does not become too dry.

The Agency for Health Care Policy and Research (AHRQ) recommends that the risk for pressure ulcers be assessed when a patient is admitted to a healthcare facility and at regular intervals (e.g., once a week) thereafter. The risk should also be assessed if the patient’s condition changes.