Description of the Categories of the Braden Risk Assessment Scale - PowerPoint PPT Presentation

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Description of the Categories of the Braden Risk Assessment Scale

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Add all together to develop a rating score (may range from 6 - 23) ... IV/TPN/Enteral/liquid supplements. will review each separately. Oral. Very poor ... – PowerPoint PPT presentation

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Title: Description of the Categories of the Braden Risk Assessment Scale


1
Description of the Categories of the Braden Risk
Assessment Scale
2
6 sub-categories
  • Sensory perception
  • mobility
  • activity
  • nutrition
  • friction/shear
  • moisture

3
Process
  • Evaluate the patients condition within each
    category
  • Assign a rating number for each
  • Add all together to develop a rating score (may
    range from 6 - 23)
  • Lower the score the higher the risk of pressure
    ulcer development

4
Sensory Perception
  • Measures ability to perceive discomfort in a
    meaningful way - may be by movement,
    communication or some other action that alerts
    the caregiver
  • The discomfort cues the patient to move self, to
    ask for help and/or express discomfort
  • Has 2 levels of potential responses
  • patient with decreased conscious state
  • patient with decreased cutaneous sensation
  • if patient has impairment in both assign the
    LOWER of possible categories

5
Decreased Level of Consciousness
  • Completely (Coma) test for response
  • cannot respond to painful stimuli - no moaning
    flinchinggrasping. Only has reflex responses
    present - flexion/extension
  • do not test using the fingers/toes or nail beds -
    may stimulate a primitive stimuli
  • Very
  • unconscious, doesnt respond to verbal
    stimuli/commands. Does flinch or moan with
    painful stimuli
  • Slightly Limited
  • responds to verbal commands, may not open eyes
  • person may be over (heavily) sedated

6
Diminished cutaneous sensation
  • Deficits usually associated with neurological
    disease that involves paralysis
  • Completely
  • cannot feel pain over most of the body -
    Quadraplegia
  • Very
  • person cannot feel pain over 1/2 of the body -
    para/hemiplegia
  • Slight
  • lack of ability to feel pain in 1 or 2
    extremities - peripheral neuropathy/chronic
    vascular disease/ neurological diseases/ MS
  • No impairment
  • Fully alert or nearly so has the ABILITY to feel
    pain - no paralysis or parasthesis

7
Moisture
  • Degree to which skin is exposed to moisture. May
    be associated with urine/ faeces/perspiration/woun
    d drainage
  • Constantly
  • moist nearly all the time - e.g constant
    dribbling perspire excessively or other
    neurological problems affecting the autonomic
    system
  • Very
  • periods of dryness (2 - 3 hrs)between episodes.
  • Occasionally
  • daily but infrequent exposure - e.g. night
    incontinence use of padding systems, use of
    moist packs that soak into surrounding skin

8
Activity
  • Measures frequency of ambulation
  • Bedfast
  • not even able to sit in chair/side of bed x1
    daily.
  • Chairfast
  • able to stand/walk only a little or not at all.
    Either sits or lies
  • walking limited to 1-2 steps . Also
    para/quadraplegic
  • Walks occasionally
  • walks 2 or more times a day but only for very
    short periods -few steps to bathroom and back to
    bed
  • Walks frequently
  • may walk outside or round room - moderate
    distance every hour or 2

9
Mobility
  • Assesses persons mobility in bed - a person may
    be in bed but at little risk if able to shift
    position
  • Mobility in bed refers to not only the ability to
    change position but also their motivation to
    change and sustain changes in position
  • Assessment shouldnt take into account
    repositioning regimes - are not relevant when
    determining degree of risk
  • Do consider the patients ability to make slight
    position changes - small changes made frequently
    are as effective as gross changes

10
Mobility Categories
  • Completely
  • cant independently make changes in position at
    all without assistance, left without help makes
    ineffectual movements
  • Very
  • occasional position changes but may not be able
    to maintain a new position, ability to change
    position inadequate or ineffectual or strong
    preference for 1 position - effects of
    sedation/depression
  • Slightly
  • can shift slightly or often, needs help to
    maintain or attain change
  • No - frequent and major changes without help or
    reminder

11
Nutrition
  • Assessment reflects USUAL intake not temporary
    status
  • 2 layers of potential responses
  • oral
  • IV/TPN/Enteral/liquid supplements
  • will review each separately

12
Oral
  • Very poor
  • diet well below requirements, rarely eats more
    than 1/3 meals eaten. Doesnt accept a supplement
  • Probably Inadequate
  • small portions sporadically, diet marginal,
    rarely eats a complete meal
  • occasional liquid supplements - drinks small
    amount
  • Adequate
  • occasionally may need encouragement to complete a
    meal, may refuse a meal, usually takes a
    supplement
  • Excellent - eating adequately, doesnt require
    supplements

13
IV/TPN/Enteric/Supplements
  • Very Poor
  • standard IV or clear fluids
  • Nil Orally for 5 days
  • poor intake before IVs/clear liquids was
    commenced
  • Probably Inadequate
  • sole source is liquid supplements takes less
    than is recommended by the manufacturer
  • Adequate
  • full regime of tube feeding/TPN
  • Excellent

14
Friction/Shear - force applied to skin surface
  • Problem
  • requires moderate/maximum assistance moving in
    bed/chair, cannot be lifted off the surface
    completely -skin slides vs the sheet, insult is
    repeated often
  • Exposed to constant friction due to
    agitation/contractures/spasticity
  • Potential Problem
  • some exposure to friction/shear can move in bed,
    requires some help skin probably slides across
    sheet.
  • Use of restraints, casts, prostheses.
    Occasionally slides down bed/chair
  • No apparent problem
  • has enough muscle strength to lift up
  • maintains good position in chair without sliding
    down

15
CALCULATION OF RISK
  • Add sub-category scores together
  • Identify equipment product type needed to support
    level of risk.
  • Note
  • Whilst overall score determines equipment type
    you must put preventative care strategies in
    place against each risk factor identified and
    monitor effectiveness.
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