Outline

• A scale is useful for predicting the occurrence of pressure ulcers.
• Among several scales, we recommend the Braden scale.
  • Its validity and reliability have been validated.
  • It is composed of 6 items which can be taken into account by nursing staff.
  • The score can be directly affect the care patients receive.

How to Use the Braden Scale

• Sensory perception: Ability to respond meaningfully to pressure-related discomfort.
• Moisture: Degree to which skin is exposed to moisture.
• Activity: Degree of physical activity. An index of not only the time of relief from pressure but also of recovery of the blood flow due to moving.
• Mobility: Ability to change and control body position. Includes the ability to change the body position to relieve pressure at areas of bony prominence and motivation of the patient to move.
• Nutrition: Usual food intake pattern according to the energy and protein intakes.
• Friction and shear: Lumped as 1 item because friction and shear occur simultaneously.

Points of attention

• The use of the scale begins when the patient becomes nearly bed-ridden.
• The intervals of evaluation is 48 hours in the acute period and 2 weeks in the chronic period. In elderly patients, the scale is applied every week during the first 4 weeks and every 3 months thereafter.
• Note that the skin must be observed daily.
• The cut-off point is 14 in hospitals and 17 in other institutions.