Pressure Injury Prevention and the Braden Scale

The Braden scale is a risk assessment tool that scores six factors linked to pressure injury: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Totals range from 6 to 23, and lower scores mean higher risk. The total tells you who needs a prevention plan; the individual subscale scores tell you what that plan should target.

What a pressure injury is

A pressure injury is localized damage to the skin and underlying tissue, usually over a bony prominence or under a medical device, caused by pressure or pressure combined with shear. The National Pressure Injury Advisory Panel (NPIAP, then called the National Pressure Ulcer Advisory Panel) changed the term from "pressure ulcer" to "pressure injury" in 2016, partly because early stages involve intact skin.

Common sites include the sacrum and coccyx, heels, hips, elbows, shoulder blades and the back of the head. Devices cause their own injuries: oxygen tubing over the ears, nasogastric tubes at the nostril, endotracheal tubes, splints and compression sleeves.

How the Braden scale works

Each subscale is scored from 1 (most impaired) to 4 (least impaired), except friction and shear, which is scored from 1 to 3.

Add the six scores for a total between 6 and 23. Your facility's policy defines which score triggers a prevention plan and how often to reassess, typically on admission, on a regular schedule and whenever the patient's condition changes. Score what you observe today, not what the last nurse charted. A complete head-to-toe assessment gives you most of what you need.

Match interventions to the low subscales

This is where the Braden scale earns its place. Two patients with the same total can need very different care.

Low sensory perception (sedation, neuropathy, spinal cord injury): the patient may not tell you something hurts. Inspect skin with every turn and check under every device.

Low moisture score (incontinence, sweating, wound drainage): - Clean skin promptly after incontinence with a gentle, pH-balanced cleanser - Apply barrier products per your facility's skin protocol - Use breathable underpads and avoid stacking several layers under the patient - Address the cause where you can, with a toileting schedule or containment devices per policy

Low activity and mobility scores: - Reposition on a schedule set by your policy and the patient's condition, and document each turn - Use a 30-degree side-lying tilt instead of placing the patient directly on the hip - Float the heels off the bed with pillows under the calves or a heel offloading device - Choose a support surface, such as a pressure redistribution mattress or specialty bed, per your facility's criteria - Get the patient out of bed and walking when it is safe, with physical therapy involved early - Limit chair time for patients who cannot shift their own weight

Low nutrition score: - Track intake and weight - Request a dietitian consult per policy - Encourage fluids and protein unless restricted, and help with meal setup and feeding

Low friction and shear score: - Use lift sheets or friction-reducing devices, and never drag the patient - Keep the head of the bed as low as the patient's condition allows, since a raised head of bed causes sliding - Apply prophylactic foam dressings to high-risk areas such as the sacrum and heels if your protocol includes them

A few practices to avoid: massaging reddened bony prominences, using ring or donut cushions, and leaving patients on piles of extra linen.

Stages you should recognize

NPIAP staging gives the whole team a shared language:

• Stage 1: intact skin with nonblanchable redness
• Stage 2: partial-thickness skin loss with exposed dermis
• Stage 3: full-thickness skin loss; fat may be visible
• Stage 4: full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage or bone
• Unstageable: the wound base is obscured by slough or eschar
• Deep tissue pressure injury: persistent nonblanchable deep red, maroon or purple discoloration, or a blood-filled blister

Redness can be hard to see in darker skin tones. Compare the area with surrounding skin for differences in color, temperature, firmness and pain, and use good lighting.

Pressure injuries are not reverse staged. A stage 4 injury that is healing is documented as a healing stage 4, not as a stage 2.

Documentation and reporting

Document skin findings carefully on admission, because injuries present on admission are tracked differently from those that develop in the hospital. Describe location, stage, size, wound bed, drainage and surrounding skin per your facility's policy. CMS counts stage 3 and stage 4 pressure injuries among its hospital-acquired conditions, so an accurate admission skin assessment matters for both the patient and the facility.

Involve your wound care team per policy for new pressure injuries, findings you are unsure about, and wounds that are getting worse.

Building wound care skills

If skin and wound care is the part of nursing you enjoy, it can grow into a specialty. The wound care management learning path covers wound assessment, staging and treatment in more depth. Read how to become a wound care nurse for the career path, and wound care certifications for nurses compared to see which credential fits. Specialized clinical skills like these can also help you move up, as covered in mastering advanced clinical skills for career progression.

Home health and hospice nurses deal with pressure injury prevention constantly, often with family caregivers doing the turning. The home health and hospice nurses group is a good place to ask how they teach it.

Next step

If prevention and wound care at home appeal to you, browse home health nurse jobs with the pay shown on every listing.

General information for nurses, not medical, legal, tax or financial advice. Follow your facility's policies, your state board of nursing and the terms of your employer or contract.