Validation of Braden

Sub Scale Scores

Whitney Olson, Elizabeth Stefely, Tessa Swenson

Current Practice

• “If Braden Score (for ages greater than 8 years) is 19-23 or Braden Q score (for ages 8 years or less) is 17-28 skin will be reassessed at a minimum every 24 hours. When Braden Score is 18 or less, Braden Q Score is 16 or less or skin assessment is abnormal, skin will be assessed every 8 to 12 hours”-SCH Skin Assessment, Prediction, and Prevention Policy

• Frequency of assessment is based on cumulative score, rather than individual sub scores.

Skin Bundle

• Foundation started with Skin Bundle. However, improvement is needed.

Staff Opinions

• “Just more charting work”.

• “Typically pick what is already being done, rather than using it for ideas of possible interventions to improve scores”.

• “Some-what reflects the Braden, but could be improved”.

• “It’s useful for some of the population on Peds. We don’t use it in the NICU”.

• For some of the Peds population it’s silly because they are kids that aren’t really in bed much. They are up playing and walking around a lot of the time”.

Sub Scale Scores

• According to Gadd (2014), a patient could benefit more from implementing interventions based on an individual subscale score rather than the cumulative Braden Scale score.

• Cox (2012), believes that in order to precisely measure pressure sore risk, modification of Braden Scale is needed. The six categories of the Braden Scale were assessed individually and recommendations for interventions were found to improve sub scale scores.

Recommendations

• Develop a new method in EPIC that will allow low subscale scores to be flagged.

• The low subscale scores could be flagged with a red exclamation point, such as other abnormal results in EPIC.

• When the low subscale scores are flagged, the nurse would be guided in EPIC through appropriate interventions or consults to be ordered.

• Skin Bundle should be revised to tailor interventions toward the six Braden sub scores versus Skin Bundle categories.

• Policy should be revised, requiring assessment of low sub scale scores every shift.

Recommendations

Continued

• Interventions would be specific to the subscales

of, sensory perception, moisture, activity, mobility,

nutrition, and friction and shear.

• When Braden sub score has improved, provide

option to discontinue orders and interventions.

• By enhancing the Braden Scale in EPIC, it could

provide guidance for implementing interventions,

enhancing documentation, and improving patient

outcomes.

Friction and Shear

Example One: Friction and

Shear• Interventions to reduce

• Do not raise HOB greater than 30 degrees (Lippoldt, 2014)

• Use a lift, rather than ‘boosting’ a patient

• If a lift is unavailable, use disposable glide sheets (Cox, 2011)

• Teach patients to move in bed using their hands and arms, rather than

their elbows and heels (Avent, 2012)

• Avoid skin-to-skin contact. Pad skin surfaces that may rub together.

• Provide preventative measures, such as transparent films,

hydrocolloids, or skin sealants. Develop criteria for use of preventative

dressings.

• Recommendations for EPIC

• Pop-up box of interventions for low scores

• Ordering of preventative measures

• Teaching guides

Example Two: Nutrition

• Interventions to improve

• Assess nutrition status of all admitting patients. (Dorner and Thomas, 2009)

• Ability for the patient to eat independently should be assessed, as well as the adequacy of total nutrient intake.

• Enhanced foods and/or oral supplements should be provided between meals, if needed.

• Provide adequate protein intake.

• Provide and encourage adequate daily fluid intake. Monitor for signs and symptoms of dehydration.

• Encourage consumption of a balanced diet

• Recommendations for EPIC

• Pop-up box of interventions

• Dietitian consult

• Ordering of enhanced foods/oral supplements

• Teaching guides

References

• Armour-Burton, T., Field, W., Outlaw, L., Deleon., E. (2013). The healthy skin project: changing nursing practice to prevent and treat hospital-aquired pressure ulcers. American Association of Critical-Care Nurses, 33(3), 32-39. doi: http://dx.doi.org/10.4037/ccn2013290

• Avent, Y. (2012). wound wise. Steer clear of friction, shear, and excess moisture. Nursing Made Incredibly Easy, 10(6), 5-8. doi:10.1097/01.NME.0000420371.77458.de

• Barrett, R., Brown, K., Bergstrom, N., Horn, S., Li, J., Omolayo, T., Rapp, M. (2013). Construct validity of the moisture subscale of the Braden Scale for predicting pressure

sore risk. Advances in Skin & Wound Care, 26(3), 122–127. doi: 10.1097/01.ASW.0000427921.74379.c5

• Beddoe, E., A., & Menella, H. (2014). Support surface mattress and/or overlay. Nursing Practice and Skill. Rertived from: CINAHL

• Cox, Jill. (2012). Predictive power of the Braden Scale for pressure sore risk in adult critical care patients. Journal of Wound, Ostomy, and Continence Nursing, 39(6), 613-621. Retrieved

from: MEDLINE .

• Dorner, B., Posthauer, M., & Thomas, D. (2009). From the NPUAP. The role of nutrition in pressure ulcer prevention and treatment: National Pressure Ulcer Advisory Panel white paper. Advances In Skin & Wound Care, 22(5), 212-221. doi:10.1097/01.ASW.0000350838.11854.0a

References

• Gadd, M. (2014). Braden scale cumulative score versus subscale scores. Journal of Wound, Ostomy, and Continence Nursing, 41(1), 86-89. Retrieved from:

MEDLINE

• Kallman, U., Bergstrand, S., Engstrom, M., Lindberg, L-G., & Lindgren A. (2013). Different lying positions and thier effects on tissue blood flow and skin temperature in older adult patients. Journal of Advanced Nurisng, 69(1), 133-144. doi: 10.1111/j.1365-2648.2012.06000.x

• Lippoldt, J., Pernicka, E., & Staudinger, T. (2014). Interface pressure at different degrees of backrest elevation with various types of pressure-redistribution surfaces. American Journal of Critical Care, 23(2), 119-126. doi: http://dx.doi.org/10.4037/ajcc2014670

• Neilson, J. (2014). Using a national guideline to prevent and manage pressure ulcers. Nursing Management, 21(2), 18-21. Retrieved from: MEDLINE

• Sibbald, G. R., Goodman, L., Nortan, L., Krasner, D. L., & Ayello, E. A. (2012). Prevention and treatment of pressure ulcers. Skin Therapy Letter. 17(8):4-7. Retrieved from: CINAHL