BRADEN SCALE
When should the first Braden Scale be assessed?
What is on admission
Soft, white, wrinkled skin from excess moisture.
What is maceration
Dead, necrotic tissue that is usually leathery, dry, and hard.
What is necrotic tissue
An area of intact skin with non-blanchable redness(redness that does not turn white when pressed), usually over a bony prominence
What is a Stage 1 Pressure injury.
Caused by mechanical forces such as bumping, friction, or shear that separate the top layer of skin from underlying tissue
What is a skin tear
What category of the Braden Scale evaluates this scenario:
A patient being repeatedly slid up in bed without a draw sheet or lift may develop deep tissue injury at the sacrum
What is fridction and shear
A proper wound description includes
location, size (length, width, depth), tissue type, exudate amount and type, odor, and the condition of the surrounding skin.
Healthy, vascularized connective tissue that fills a wound cavity. It appears moist, granular, and bright red or pink.
What is granulation tissue
DTI
What is localized area of damaged soft tissue under intact or non-intact skin, appearing as a dark bruise, maroon, or purple discoloration, or a blood-filled blister
Caused by severe, chronic lack of oxygenated blood flow (ischemia) to lower extremities
What are arterial ulcers
The Braden Scale evaluates 6 categories.
What are: Sensory Perception, Moisture, Activity, Mobility, Nutrition, and Friction/Shear
Excessive granulation tissue that rises above the level of the wound edges, which potentially delays epithelial tissue from forming. It appears red, moist, and often friable tissue, and may require intervention to manage.
What is hypergranulation tissue
Light pink, shiny, and indicates the wound is closing.
What is epithelial tissue
Stage 2 Pressure injury
What is partial-thickness skin loss involving the epidermis and part of the dermis. It may also present as an intact or ruptured serum-filled blister.
Caused by a severe post-operative complication where the edges of a closed surgical wound separate or reopen, commonly occurring 5–8 days post-surgery
What is a surgical incision dehiscence
A dietary consult will help a resident with a low Braden Score by?
What is providing protein supplements and monitoring food and supplement intake.
Periwound firmness, which may indicate infection or pressure.
What is induration
Non-viable, devitalized tissue that is often yellow stringy, slimy, or thick. It can adhere to the wound bed
What is slough
Structures involved with a Stage 4 Pressure injury
What are muscles, tendons and bone
Caused by chronic blood pooling due to damaged vein valves, causing high pressure, fluid leakage, and tissue breakdown, typically near the ankles.
What are venous ulcers
Braden Score that indicates High Risk
What is 10-12.
A complication where the tissue under the wound edges detaches from the underlying structures, creating a "shelf" or pocket
What is undermining
Thick, dry, adhered epidermal tissue often found on the edges of chronic, high-pressure wounds
What is a callus
Full thickness tissue loss in which the base of the pressure injury is covered by slough or eschar
What is an Unstageable Pressure injury
A combination of nerve damage (neuropathy), poor circulation (peripheral artery disease), and unnoticeable trauma, such as a blister.
What are diabetic foot ulcers