Braden Scale For Predicting Pressure Sore Risk

Braden Scale For Predicting Pressure Sore Risk

How to use the Braden scale Each patient is assessed for the following risk factors: Sensory Perception Moisture Activity Mobility Nutrition Friction and Shearing Each risk factor is rated on a 1-4 scale A score of LESS THAN 18 indicates HIGH RISK Score patients as they are at that moment in time

Sensory Perception Ability to response meaningfully to pressure-related discomfort Score 1 if COMPLETELY LIMITED Unresponsive to painful stimuli (does not moan flinch or grasp) due to LOC or sedation OR limited ability to feel pain over most of body IE: on paralytics; in coma or stuporous state Score 2 if VERY LIMITED responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment that limits the ability to feel pain over 1/2 of body IE: patients who only moan but can t communicate pain; patients with paralysis

Sensory Perception Ability to response meaningfully to pressure-related discomfort Score 3 if SLIGHTLY LIMITED Responds to verbal commands but cannot always communicate discomfort or need to be turned OR has some sensory impairment which limits ability to feel pain or discomfort in 1-2 extremities IE. Severe arthritics unable to turn, stroke patient Score 4 if NO IMPAIRMENT Responds to verbal commands. Has no sensory deficits which would limit ability to feel or voice pain or discomfort IE: walkie-talkie

Moisture: Degree to which skin is exposed to moisture ie. Incontinence, perspiration, drainage Score 1: if Constantly Moist Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned IE. C diff patient, frequently incontinent of urine or stool Score 2: Often Moist Skin is often but not always moist. Linen must be changed at least once a shift IE: Incontinent of urine, copious drainage from wound

Moisture: Degree to which skin is exposed to moisture ie. Incontinence, perspiration, drainage Score 3: Occasionally Moist Skin is occasionally moist, requiring an extra linen change approximately once a day IE. Diaphoretic. Draining wound Score 4: Rarely Moist Skin is usually dry: linen only requires changing at routine intervals IE. Patient continent of urine, no drainage or perspiration

Score 1: Bedfast Confined to bed Activity Degree of physical activity Score 2: Chairfast Ability to walk severely limited or nonexistent. Cannot bear own weight and / or must be assisted into a chair or wheelchair Score what the patient is doing NOT what they are capable of doing

Activity Degree of physical activity Score 3: Walks Occasionally Walks occasionally during the day but for very short distances with or without assistance. Spends majority of each shift in bed or chair IE. CHF patient with activity intolerance Scores 4: Walks Frequently Walks outside the room at least twice a day and inside room at least once every 2 hours during waking IE Walkie talkie

Mobility Ability to change and control body position Scores 1: Completely immobile Does not make even slight changes in body or extremity position without assistance IE. Paralyzed, severe stroke patient Scores 2: Very Limited makes occasional slight changes in body or extremity position but unable to make frequent changes or significant changes independently IE. Fractured hip patient Score what the patient is doing NOT what they are capable of doing

Mobility Ability to change and control body position Scores 3: Slightly Limited Makes frequent though slight changes in body or extremity position independently Scores 4: NO Limitations Makes major and frequent changes in position without assistance

Nutrition Usual food intake pattern Scores 1 : Very Poor Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less protein (meat or dairy products) per day. Takes fluids poorly, no liquid dietary supplements OR is NPO or Clear liquids or IVs for >5 days 1/3 Scores 2: Probably Inadequate Rarely eats a complete meal. Generally eats only 1/2 of food offered, Protein intake includes only 3 servings of meat or dairy products per day. Occasionally takes a dietary supplement OT receives less than optimal amount of liquid diet or tube feeding IE. Patient just starting on tube feeding

Nutrition Usual food intake pattern Scores 3: Adequate Eats over 1/2 of most meals. Eats 4 servings of protein (meat and dairy products) each day. Occasionally will refuse a meal but will usually take a supplement OR is on a Tube feeding or TPN regiment which meets most nutritional needs IE. Tube feeding at 80ml/hr Score 4: Excellent Eats most of every meal. Never refuses a meal. Eats 4 or more servings meat or dairy. Occasionally eats between meals Doesn t need supplements IE. Healthy eater

Friction and Shearing Score 1: Problem Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with max assistance. Spasticity, contractures, or agitation leads to almost constant friction

Friction and Shearing Score 2: Potential Problem Moves feebly or requires minimal assistance. During a move, skin probably slides against sheets/ devices. Maintains good position in bed most of the time but occasionally slides down Scores 3: No Apparent Problem Moves in bed independently and has sufficient muscle strength to lift up completely during a move. Maintains good position in bed at all times

Transparent Dressings Transparent dressings are constructed from a thin film backing coated with a hypoallergenic, water resistant adhesive. They allow for gas and vapor exchange while providing a barrier to outside contaminants. Change for leaking May be left in place for up to 7 days

Hydrocolloid Moisture retentive adhesive dressing composed of a flexible crosslinked adhesive mass containing gelatin,pectin, carboxymethylcellose particles Reassess after 48 to 72hrs

Hydrogels Contains mostly water with some polymers Used to autolytically debride a wound. Used for partial or full thickness wounds Used for thermal burns Used for dry or lightly exudating wounds

Foam Dressings Semipermeable hydrophilic polyurethane foam dressing Reapply dressing when it becomes loosened, saturated, or soiled Special order product with consult to skin care nurse. Ex: Lyofoam, Curaforam, CarraSnart, VigiFoam

Calcium Alginates Gift from the sea! Calcium Alginates are made of seaweed and absorb 20 times their weight These are non woven dressings made from calcium alginate fibers. Alginates form a gelatinous mass as they absorb wound exudate, promoting a moist healing environment Special order that requires a skin care consult (comes in ropes or pads) Ex: Sorbsan, Kaltostatm Carrasorb, Curasorb

Wound Solutions Normal Saline Hydrogels Betadine Acetic Acid Hydrogen Peroxide Dakins Solutions

Normal Saline isotonic the bodily fluids friendly to tissue cells provides a moist environment for wound healing no antibacterial coverage ideal for wound cleansing

Hydrogels adds moisture to maintain a moist wound environment. Its slightly acidic nature promotes healing Provides more moisture than normal saline so do not disturb wound bed more than every 12 hours

Betadine Provides broad spectrum effectiveness when used on intact skin or small clean wounds Can be toxic to fibroblasts in normal dilutions (if used it should be 1/4 to 1/2 strength Not always effective in infected wounds Long term use in large numbers may cause iodine toxicity

Acetic Acid Can be effective against Pseudomonas aeruginosa in superficial wounds Toxic to fibroblasts in standard dilutions May change the color of exudate, which may provide false assurance that the infection has been eliminated

Hydrogen Peroxide Provides mechanical cleansing and some debridement by effervescent action Toxic to fibroblasts Can cause ulceration of newly formed tissue DO NOT use to pack sinus tract (can cause air embolism DO NOT use for forceful irrigation (can cause subcutaneous emphysema)

Dakin s solution Effective against Staphylococcus and Streptococcus species Dissolves necrotic tissue Controls odor Toxic to fibroblasts in normal dilutions Protect intact surrounding skin to prevent breakdown

Gauze Kerlix ABD pads Kling Telfa Adaptic Vaseline Gauze NU gauze Dressings

Gauze IE. Gauze sponges Cotton woven gauze Well suited for dressing, cleaning, packing, and debriding wounds

Fluff woven gauze that offers bulk and high absorbency. Secondary dressing used to secure primary dressing without tape Ideal for wrapping extremities Kerlix

ABD pads IE. Kendall Tendersorb 3 layer soft outer nonwoven layer with fluff filler to absorb and disperse fluid and a wet proof moisture barrier to retard fluid strike through edges slated to prevent lint residue

Telfa- Non-adherent Dressing Cotton pad Won t disrupt healing tissue by sticking to wound. Ideal as primary dressing for lightly draining wounds

Adaptic Dressing Oil emulsion blend impregnated into open mesh knitted fabric dressing Non-Adhering to wound site Allows free drainage of exudate away from wound

Vaseline Gauze Non adherent impregnated with 3% Bismuth tribromophenate in a petrolatum blend on a fine mesh gauze Use when chest tubes discontinued for an occlusive dressing. Do not use a chest tube daily dressing as petroleum can cause maceration

100% cotton fine mesh gauze ideal for wet to dry packing Helps to control bleeding and prevent pooling of wound fluid NU Gauze

Types of Debridement Debridement: is indicated when necrosis or slough is present Autolytic: (Mechanical) Sharp: (Surgical) Enzymatic: (Chemical)

Autolytic Debridement Coverage of an ulcer with dressing materials that retain wound moisture to allow the body s own enzymes in wound fluid to digest dead tissue. (wet to dry drssings) + selectively debrides necrotic tissue, May be used for patients who cannot tolerate other forms of debridement - takes longer than other debridement methods Progress should be visible in 2-3 days

Sharp: (Surgical) Surgical removal of dead tissue + immediate treatment of choice if patient is septic - non selective, painful, requires specialized skill

Enzymatic: (Chemical) Ex: Collagenase Santyl Loosens necrotic debris Takes longer than sharp debridement but may be faster than autolytic

Advanced Wound Care Compression Bandages Wound Pouching Negative Pressure Therapy VAC

Compression Bandages Reduced blood pressure in superficial venous system Aid venous return to the heart Reduces edema by reducing the pressure difference between the capillaries and the tissue With venous ulcers, these issues must be addressed to heal the wound. Change elastics bandages at least BID to sustain pressure

UNNA Boot

Wound pouching is a way to manage highly exudating wounds that are macerating surrounding tissues or to manage fistulas The pouch is cut to fit the opening of the wound and the surrounding skin is protected by the stomadhesive base of the pouch Wound Pouching

Negative Pressure Therapy VAC Foam dressing placed in wound covered by a film dressing that has subatmospheric pressure applied Removes edema leading to localized blood flow Removes wound fluid, bacterial counts

VAC: Vacuum Assisted Closure Consists of 5 items: Machine Canister Foam: Black or White Drape / Dome with tubing Tegaderm

Setting machine Press THERAPY Press Continuous Press ON Machine will default to 125mmGH, adjust up of down with arrows per MD order Q shift: Check the machine is ON, Continuous, and pressure per MD order

Incisional Negative Pressure Therapy PICO Prevena

The Results With the assist of Vacuum Assisted Closure, wounds like this can heal!!!

Unstageable pressure injury Stage 1 Stage 2 Stage 3 Stage 4 Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed Deep tissue pressure Injury Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Presence of blanchable erythema or changes to sensation temperature or firmness may precede visual changes Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue

Fecal Incontinence Toolkit SAGE Dimethicone Wipes Nutrashield Calmoseptine Can be ordered from Inventory WIPE7905 Flexiseal OR from your Supply carts Low Air Loss Rental Mattress Insertion kits from Sue Hoban on days or Nursing Supervisor Call 1-800-343-0970 to rent a First Step Select

BE NOT AFRAID Don t be afraid to try something new Remember an amateur built an arc and a whole group of professionals to build the titanic!!!