By David Wheeler

1. The Braden Scale
and Critical Thinking
Pressure Injury Prevention
By David Wheeler
Before you begin click here to take the Pre-Survey

2. How Do You Prevent Pressure Injury (PI)?
Complete the Braden Scale?
Rely on personal nursing experience?
Trust that charting in the electronic
health record (EHR) is enough?
Utilize critical thinking with the Braden?

3. Background
Pressure injuries are a
serious concern for the
hospital and the
patient.

4. From the Patient’s Perspective
“Research shows that pressure ulcers and their treatment
negatively affect every dimension of a patient’s life:
emotional, mental, physical, and social. Patients in one study
reported experiencing “endless pain,” and those in another
said that nursing staff didn’t acknowledge or treat their
discomfort and pain (although they received many pressure
ulcer–related interventions). Even usual nursing care, such as
turning, has been found to be painful for patients with
pressure ulcers.”
Stotts, N. A., & Gunningberg, L. (2007). How to try this: predicting pressure ulcer
risk. Using the Braden scale with hospitalized older adults: the evidence supports it.
The American Journal of Nursing, 107(11), 40–48; quiz 48–49.

5. Facts on Pressure Injury
 Affects 14% to 25% of patients
 1.2% of health care expenditures in the U.S.
 Cost to heal a single pressure ulcer: $3,500 to
$60,000
 More than 17,000 lawsuits filed annually,
$250,000 per judgement
Baumgarten M, et al. Pressure ulcers among elderly patients early in the hospital
stay. J Gerontol A Biol Sci Med Sci 2006;61(7):749-54

6. Hospitalizations Related to Pressure
Ulcers among Adults 18 Years and
Older, 2006
C. Allison Russo, M.P.H., Claudia Steiner, M.D., M.P.H., and William Spector, Ph.D.

7. Hospitalizations Related to Pressure
Ulcers among Adults 18 Years and
Older, 2006
C. Allison Russo, M.P.H., Claudia Steiner, M.D., M.P.H., and William Spector, Ph.D.

8. Objectives
The Braden Scale and Critical Thinking
 Scoring and Interpreting the Braden Scale
 Subscales are Important Determinants for PI
 Risk Factors not Captured by the Braden
 Medical Device Related PI

9. Rethinking Assessment
o Do you think it is just a task?
o Have you lost the critical
thinking piece while charting in
the EHR?
o How often do you find yourself
“copying forward” the last
assessment?
o Have you modified the care
plan produced by the EHR?
A global perspective on clinical and policy standards in pressure ulcer reduction September 10, 2012
Elizabeth A. Ayello

10. Defining a Pressure Injury
 Localized damage to the skin or soft tissue usually
occurring over over a bony prominence
 May be related to a medical device
 Intact skin or an open ulcer and may be painful
 Occurs as a result of intense or prolonged pressure
 Other factors include: microclimate or moisture,
nutrition, perfusion, co-morbidities affecting the
soft tissue
EPUAP, NPUAP, Pan Pacific Pressure Injury Alliance. Prevention and
Treatment of Pressure Ulcers: Clinical Practice Guideline. 2014

11. Some Myths About PI
Patients should be repositioned no more
than every 2 hours while in bed.
Turning schedules should be individualized
depending on the patient’s needs.
 Turning every 2 hours in bed
 Repositioning every hour in chair
 OR more frequently as needed
Bergstrom N, Bennett MA, Carlson CE, et al. Treatment of Pressure Ulcers. Clinical Practice
Guideline, No.15. AHCPR Publication No. 95-0652. Rockville MD: Agency for Health Care Policy
and Research; December1994

12. Some Myths About PI
A reddened area is not a pressure ulcer.
Reddened area may be an indication of a Stage I
pressure ulcer
 Intact skin
 Non-blanchable redness usually on bony
prominences
 Blanchable red areas are NOT Stage I PI,
but are a sign the patient is at high risk!
National Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention Points. Washington DC:
NPUAP; 2007

13. Some Myths About PI
Patients who can shift their own weight and reposition
themselves don’t need to know about pressure ulcer
prevention.
 Education all patients including those who can shift
their own weight and reposition themselves
 Educate families and caregivers on repositioning and
include them in the care plan
 Encourage patients to change positions frequently and
monitor repositioning
Bergstrom N, Bennett MA, Carlson CE, et al. Treatment of Pressure Ulcers. Clinical Practice
Guideline, No.15. AHCPR Publication No. 95-0652. Rockville MD: Agency for Health Care Policy
and Research; December1994

14. The Braden Scale
 Developed in the 1980s by nurses
Barbara Braden and Nancy
Bergstrom, who developed the
critical determinants of Pressure
Ulcer Development
 What is the intensity and
duration of pressure?
 What is the Ability of the skin
and supporting tissues to
tolerate the pressure?

15. Is the Braden Scale
Accurate?
 Highly effective in
predicting risk factors
 Reliability: 0.83 to 0.99
 Sensitivity or patients at
risk
 83%
 Specificity or patients not
at risk
 64%

16. Braden Scale Risk
Factors
1. Sensory and Perception
2. Moisture
3. Activity
4. Mobility
5. Nutrition
6. Friction and Shear

17. Scoring the Braden
Risk factors are scored 1-4, with friction/shear scored
1-3. Total scores will range from 6 to 23, and a score
of 18 or less indicates a patient is at risk.
 Note: a low score in one Braden subscale
places the patient at a higher risk for PI
regardless of the total score!

19. If the Braden Scale is so Reliable
how can a Patient with a Score of 19
Develop a PI?
 No tool has perfect predictability
 Patients at low risk may need interventions for a
subscale that is low
 Example: the total Braden score is 19, but the
nutrition subscale is 1
 Include medical co-morbidities and factors not
captured by the Braden Scale
 Let tools supplement your critical thinking

20. Case Study
 Ms. P is a 78 year old female admitted to the
intermediate care unit. She presented to the ED
after being seen in the clinic.
 T: 101.4
 BP 98/44
 complaints of headache, lower back pain,
nausea, along with diarrhea for the last two days
and one episode of vomiting

21. Past Medical History (PMH)
Kidney transplant 4 months ago, and co-morbidities
including CHF with frequent hospitalizations, COPD,
morbid obesity with a BMI of 41.3, chronic back pain
with a diagnosis of spinal stenosis, occasional
urinary incontinence due to urgency, DMII, on SSI
insulin along with prandial insulin before each meal
and long acting at bedtime.

22. PMH
Her blood sugars have been between 225 to 250
over the last month. She reports having chronic
anemia, and peripheral artery disease affecting her
right leg with a bypass performed a year ago to
improve blood flow. Other pertinent history includes
paroxysmal afib, currently controlled and on
Coumadin. She is currently on 5 mg of prednisone
and blood pressure and immunosuppressive
medications.

23. Admission
Her primary care team, kidney transplant, asks for
the patient to be evaluated in the ED for her low Bp
and a WBC count of 22, and then admitted to the
intermediate care unit, diagnosis of possible sepsis.

24. Admitted to the Unit
Ms. P arrives on the unit and is settled in her room.
A skin check with two nurses finds that she has red
heels that are blanching, the skin on her sacrum is
red but blanching, the backs of the elbows, ears,
and sacrum are intact. Mrs. P reports that she has
not felt well for the last 2 weeks, has resorted to
using a walker at home and has not ventured out of
the house except for clinic appointments.

25. Assessment
She spends most days at home between bed and
couch. She walks from the wheel chair to the bed,
but states she was too weak to walk earlier and the
staff transported her to the ED in a wheelchair. She
reports her eating is unaffected for the most part.
Her typical diet is toast in the morning, she is not
hungry for lunch, and eats about half of her dinner.
Ms. P is found to be alert and oriented to time,
person, and place and reports back pain of an “8”

26. Ms. P’s Braden Assessment
Sensory and Perception
This subscale measures the “ability to respond
meaningfully to pressure-related discomfort” by
assessing the patient’s perception of pain and level
of consciousness. Ms. P is alert and oriented, she
scores her back pain an 8, and reports her right
lower right leg has been feeling “strange”, a little
numb, and reports she doesn’t feel the discomfort
in that leg the same as she does in her left leg.

28. Ms. P’s Score
Sensory and Perception
A patient who is alert and oriented and can feel
pain should score a 4, but because Ms. P reports a
lessened ability to feel discomfort in her right leg,
the nurse scores this subscale a 3.
 She has some sensory impairment which limits
ability to feel pain or discomfort in 1 or 2
extremities.

29. Ms. P’s Score
Moisture
Rate the degree to which the skin appears to be
moist. Mrs. P appears exhausted after the events of
the morning and during the initial skin inspection
the nurse notes she is diaphoretic. She is wearing a
brief which Is dry. She reports wearing one daily for
incontinence. Because she is diaphoretic and may
require a change of sheets at least once a day the
nurse rates her a 3.
 Skin is occasionally moist, requiring an extra
linen change approximately one a day.

31. Ms. P’s Braden Assessment
Activity
Ms. P is walking but It may be difficult to choose
between chairfast and walks occasionally.
 Chairfast: Ability to walk severely limited or non-
existent. Cannot bear own weight and/or must
be assisted into chair or wheelchair.
 Walks Occasionally: Walks occasionally during
day, but for very short distances, with or without
assistance. Spends majority of each shift in bed
or chair.
How would you rate her ability to walk?

33. Ms. P’s Score
Activity
 Ms. P is rated a 3, Walks Occasionally
 She was able to walk assisted from wheelchair to
bed
 Too weak to walk earlier today
 Reports not walking much the last two weeks
except from bed to couch

34. Ms. P’s Braden Assessment
Mobility
 The nurse asks Ms. P to roll onto her left side so that
a protective Mepilex may be applied to her sacrum.
 She has difficulty turning more than 20 degrees
without assistance.
 She reports difficulty getting out of bed in the
morning.
 We do not have a baseline on how well or often she
is able to move in bed.
 The nurse debates whether she should receive a
score of 2 or 3.

36. Ms. P’s Score
Mobility
The nurse consider two choices:
 Score 2: Very Limited
 Makes occasional slight changes in body or
extremity position but unable to make frequent
or significant changes independently.
 Score 3: Slightly Limited
 Makes frequent though slight changes in body or
extremity position independently.

37. Ms. P’s Score
Mobility
 The nurse decides on a score of 2
 Ms. P can make slight changes independently as
demonstrated by her ability to move less than 30
degrees to her side
 She is unable to move more than that; unable to
make significant changes to her body position
without assistance

38. Ms. P’s Braden Assessment
Nutrition
 It can be challenging to perform an accurate
nutrition evaluation
 Assessment of oral intake requires knowledge of the
patient’s eating patterns over several days
 Assessment should take into account NPO status and
tube feedings
If tube feeding is not at goal assign a 2: “less than
optimum amount of liquid diet or tube feeding.”

40. Ms. P’s Score
Nutrition
 Ms. P reports to the nurse that she feels her nutrition
is good and she wishes she could loose weight
 The nurse notes previous statements regarding
appetite and decides that her nutritional intake is
insufficient
 toast for breakfast
 often skips lunch
 typically eats half of dinner
 She is rated a 2 for inadequate

41. Ms. P’s Braden Assessment
 Friction: two surfaces in contact move in
opposite directions
 May result in superficial scuffing or abrasion of
the skin
 Shear: created when skin stays stationary
while fascia and muscle move in the opposite
direction
 Occurs when a patient slides down in bed
 May cause blood vessels to be pinched shut
resulting in ischemia and tissue necrosis.

43. What Happens When a Patient is Upright in Bed

44. Ms. P’s Score
Friction and Shear
 CT scan is ordered and radiology and requests
the patient be on a green lift sheet
 The nurse notices that over the last hour she has
slid down in the bed twice and had to be
repositioned with the overhead lift
 The nurse scores friction and shear a 1 since Ms.
P is frequently sliding down in the bed

46. Ms. P’s Braden Assessment Score
A total Braden score of 14 indicates that Ms. P is
at moderate risk for a PI.
 Lower scores suggest higher risk and require
more aggressive preventive efforts.
 Of foremost concern are the subscale scores in
mobility, nutrition, and friction/shear subscales.

47. Coming Up With a Care Plan
 Review areas of risk identified by the Braden Scale and
risk factors related to PMH and identified in the physical
assessment.
 Select interventions to address low subscale scores
regardless of the total score.
 Share the plan with family members and encourage their
involvement.
 Modify the individualized plan of care produced by the
EHR.
All patients at risk should have heels and sacrum, the most
commons sites for PI protected.

48. A Care Plan for Ms. P
 The nurse places
Mepilex protection to
Ms. P’s heels and to
her sacrum since she
may be spending
much of her time in
bed or chair

49. Floating Heels
 Best practice is to place a pillow vertically underneath
each calf rather that one pillow horizontally

50. Care Plan for Ms. P
 The nurse decides that Ms. P should be tuned every two
hours since she was unable to turn more than 20 degrees
without assistance.
 The nurse writes a turning schedule on the White Board as
a reminder
 She asks the patient and family members present to speak
up if a turn is overdue.

51. Care Plan for Ms. P
 A nutrition consult is ordered because of Ms. P’s
low score in the nutritional subscale
 Ms. P is also had a low score in the Friction/Shear
subscale and is at greater risk.
 The head of the bed will be at 30 degrees except
when Ms. P is upright for meals

52. Care Plan for Ms. P
 Mrs. P scored low in Sensory Perception because
she reports an inability to feel discomfort in her
right leg
 The nurse will elevate this leg with a pillow
 When Ms. P is out of bed a waffle cushion is
placed in the chair and she is reminded/assisted
to reposition every hour

53. Care Plan for Ms. P
 Patients with lower Braden scores, subscales
scores, or an abnormal BMI may benefit from a
specialty bed
 The nurse decides to consult with the wound care
nurse on whether the patient may benefit from a
specialty bed

54. What are the Challenges with
Nutrition Subscale?
“It can be challenging to complete an accurate evaluation for the nutrition subscale.
This subscale scores “usual” intake and is applicable to eating as well as to feeding
methods such as IVs, total parenteral nutrition, or tube feeding. Assessment of oral
intake requires knowledge of the patient’s eating patterns, so data must be gathered
over several days. If a patient is nonresponsive upon admission and family or friends
cannot report on intake, nutritional status can be evaluated using BMI and serum
albumin level; the assessment will also take into account current plans for the
patient’s nutrition (for example, if the patient has an injury that will prohibit intake
or she or he is to take nothing by mouth for several days for tests or treatments).
Clinical judgment is used to assign a score. The rule of thumb is to “do no harm,” so if
the data are borderline, assign a lower risk score.”
“Similarly, because it often takes several days for tube feeding target goals to be
reached, the patient may be underfed. In this case, a score of 2 should be assigned
because the patient is receiving “less than [the] optimum amount of liquid diet or
tube feeding.”
Stotts, N. A., & Gunningberg, L. (2007). How to try this: predicting pressure ulcer
risk. Using the Braden scale with hospitalized older adults: the evidence supports it.
The American Journal of Nursing, 107(11), 40–48; quiz 48–49.

55. Risk Factors Outside the Braden
 Obesity
 Affects mobility
 Results in compromised tissue perfusion
 Medical Co-morbidities
 DM
 Edema
 CHF
 Medications
 Transplant patients on steroids which can
aggravate DM and weaken skin integrity
Rapp MP, Bergstrom N, Padhye NC. Contribution of skin temperature
regularity to the risk of developing pressure ulcers in nursing facility
residents. Adv Skin Wound Care 2009;22(11):506-13

56. Risk Factors in Critical Care
Patients
Assess Co-morbidities and Medications
• Perfusion and oxygenation
• Nutritional deficits
• Higher rates of Steroids in
• transplant patients
• CHF
• COPD – PVD
• DM
• Obesity
• Hypotensive episodes and
• hemodynamic instability
• Medical Devices
• Perioperative Patients

58. What Can Possibly Go Wrong?
 A short case study describes a patient with a
Braden score placing him at no risk for PI
 Patient developed a PI within the first week
 Could attention to subscales have prevented this?

59. Case Study Mr. D
• 65 year old male who is well nourished and
ambulatory and presents to the ED with c/o coughing
yellow and blood tinged sputum, chills, and left-sided
chest pain.
• PMH: pneumonia, COPD, emphysema, use of nasal
intermittent positive pressure ventilation (NIPPV) at
night along with home oxygen. HTN, DMII,
gastrointestinal bleeding, diverticulitis, and
pancreatitis. 50 year pack h/o smoking, ceasing in
1990. Reports being independent with ADLs at home.
Gadd, M. M. (2014). Braden scale cumulative score versus subscale scores:
Are we missing opportunities for pressure ulcer prevention? Journal of
Wound, Ostomy and Continence Nursing, 41(1), 86–89.

60. Admission
• Vitals: 36.9, 139/59, HR 81, RR 18, 86% on RA and
92% on 3L NC.
• A&O x4, no skin breakdown, elevated WBC, CXR
with left lung infiltrate.
• DX: Pneumonia, COPD exacerbation, exercise
intolerance, DMII

61. Hospital Course
• Mr. D stayed in the hospital for 16 days
• Developed the first PI on day 7
• Developed the second PI on day 16
• He was discharged on day 16 with both PIs

62. Days 1 to 6
A. Total Braden score was 18 on 1 day, and 20 to 22
on the other 5 days
a. Braden subscales were suboptimal during this
same time
B. On day 2 the total Braden placed the patient at
NO risk, but he scored low in:
a. sensory perception
b. Activity
c. mobility subscales.

63. Day 7: Deep Pressure Injury
 On day 7 Mr. D’s total Braden score was 23.
 A deep pressure injury (DPI) to the coccyx was
found
 Gadd suggests that the DPI is consistent with the
lower subscale scores
 Sensory perception
 Activity
 mobility
Gadd, M. M. (2014). Braden scale cumulative score versus subscale scores:
Are we missing opportunities for pressure Uucer prevention? Journal of
Wound, Ostomy and Continence Nursing, 41(1), 86–89.

64. The Next 8 Days
• During this time the total Braden score indicated
NO risk.
• He had a total of 5 suboptimal subscales during
4 of 5 days
• He had a nutrition consult placed at admission
and this subscale was not scored

65. Day 16: 2nd PI
Found
 Stage 3 to the
coccyx
 Located in a
different area than
the first

66. Why the 2nd PI?
• Lower activity subscales due to activity
intolerance associated with pneumonia, tissue
hypoxia, nighttime immobility with use of NIPPV,
DMII
• Sensory Perception suboptimal 22% of the time
• Activity suboptimal 56% of the time
• Mobility suboptimal 56% of the time
• Friction/Shear Suboptimal 17% or the time
Gadd, M. M. (2014). Braden scale cumulative score versus subscale scores:
Are we missing opportunities for pressure Uucer prevention? Journal of
Wound, Ostomy and Continence Nursing, 41(1), 86–89.

68. Discussion
 Failure to implement PI prevention when the
patient’s cumulative score was high but
individual sub scores were suboptimal?
 When total scores are greater than 18 are
subscales ignored?
 Should interventions be based on subscales and
not the total Braden score?
Gadd, M. M. (2014). Braden scale cumulative score versus subscale scores:
Are we missing opportunities for pressure ulcer prevention? Journal of
Wound, Ostomy and Continence Nursing, 41(1), 86–89.

69. Day Two for Ms. P
 On the 2nd day of her admission Ms. P is unable to
maintain her oxygen saturation and is placed on
oxygen via a nasal cannula and BIPAP at night
 Foley catheter is placed since is had fluid
overload and will receive Lasix
 Bilateral weeping edema to lower extremities
 Ms. P at risk for a medical device related PI

70. Devices May Cause Injury
1. Not captured by the Braden assessment
2. What are the patient’s risk factors?
 Foley tubing laying under her edematous legs
may impede circulation
 The patient has SCDs over her lower legs
 A BIPAP may compromise facial tissue

72. Recommendations
• Consider all patients with a medical device to
be at risk
• Inspect the skin around and under medical
device at least twice a day looking for signs of
pressure-related injury and perform ongoing
skin assessment throughout the shift
• Inspect the skin more than twice a day if the
patient is at risk for fluid shifts or shows signs
of localized or generalized edema
• Remove potential device-related sources of
pressure as soon as possible

73. In Closing
Thank you for participating in this education and
don’t forget to utilize critical thinking skills!
Click here for the Post-Survey

74. References
Institute for Healthcare Improvement. Five million lives cam- paign. Prevent pressure ulcers: getting
started kit. 2006. http:// www.ihi.org/IHI/Programs/Campaign/PressureUlcers.htm.
Wound, Ostomy, and Continence Nurses Society. Guideline for the prevention and management of
pressure ulcers. Mount Laurel, NJ; 2002. Report 000-2002.
American Medical Directors Association. Pressure ulcers [Clinical Practice Guideline]. Columbia, MD;
1996. CPG2.
Virani T. Risk assessment and prevention of pressure ulcers. Toronto, ON: Registered Nurses’ Association
of Ontario, Nursing Best Practice Guidelines Program; 2005. http://www.guideline.
gov/summary/summary.aspx?doc_id=7006&nbr=004215& string=pressure+AND+ulcers.
Folkedahl BA, Frantz R. Prevention of pressure ulcers. Iowa City, IA: University of Iowa Gerontological
Nursing Interventions Research Center, Research Dissemination Core; 2002 May.
http://www.guideline.gov/summary/summary.aspx?doc_id= 3458&nbr=2684.
John A. Hartford Institute for Geriatric Nursing. Assessment Tools- Try This.
http://www.hartfordign.org/practice/try_this/
Lyder CH, Wang Y, Metersky M, et al. Hospital-acquired pressure ulcers: results from the National
Medicare Patient Safety Monitoring System Study. J Am Geriatr Soc 2012;60(9):1603-8.

75. References
National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific
Pressure Injury Alliance. Prevention and treatment of pressure ulcers: clinical practice guideline.
Perth, Australia: Cambridge Media; 2014.
Niederhauser A, VanDeusen Lukas C, Parker V, et al. Comprehensive programs for preventing
pressure ulcers: a review of the literature. Adv Skin Wound Care 2012; 25(4):167-88.
Rapp MP, Bergstrom N, Padhye NC. Contribution of skin temperature regularity to the risk of
developing pressure ulcers in nursing facility residents. Adv Skin Wound Care 2009;22(11):506-13.
Shanks HT, Kleinhelter P, Baker J. Skin failure: a retrospective review of patients with hospital-
acquired pressure ulcers. World Council Enterostomal Ther J 2009;29(1):6-10.
Wong VK, Stotts N, Hopf HW, et al. Changes in heel skin temperature under pressure in hip
surgery patients. Adv Skin Wound Care 2011;24(12):562-70.
EPUAP, NPUAP, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers:
Clinical Practice Guideline. 2014.
NPUAP.org: “The Unavoidable Outcome: A Pressure Injury Consensus Conference” Published: J
Wound Ostomy Continence Nurs. 2014;41(4):1-22
Cock, K. Anti-embolism stockings: are they used effectively and correctly? Bri Jour Nsg 2006:Vol
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