How to Use the Braden Scale: Overview and FAQ

Pressure ulcers are preventable injuries that can cause patients’ conditions to deteriorate and increase their length of stay. They’re also the direct cause of an estimated 60,000 deaths and cost the U.S. healthcare system up to $11 billion annually. Implementing the Braden Scale risk assessment tool is an effective way to reduce these potentially fatal injuries.

Predicting pressure ulcers is one way to mitigate the risks. By implementing the Braden score scale into the nursing workflow, facilities can increase awareness and prompt nurses to take the next steps in preventing pressure ulcers.

The following provides an overview of the Braden Scale, scenarios (with answers to common questions), and information to help your staff use it effectively at your facility.

What Is the Braden Scale?

This scoring tool, developed by Barbara Braden and Nancy Bergstrom in 1988, is used to predict a patient’s risk of developing a pressure ulcer. The tool is meant to help nurses flag certain risk factors for pressure injuries. It takes into account risk factors like nutritional status and mobility challenges. The Braden Scale can be integrated into a documentation system, such as a nursing head-to-toe assessment flowsheet.

The scoring system is divided into six subsections, where a patient is graded on a scale of one to four, with one being the most limited and either three or four being the most independent. Total scores range from 6-23, with lower scores indicating higher risk for developing a pressure injury and higher scores pointing to a lower risk. A patient with a score of 18 or less is considered high-risk for pressure ulcers.

What Is a Pressure Injury?

Long periods of uninterrupted pressure on the skin, soft tissue, muscle, and bone cause pressure injuries, often referred to as “bedsores.” The pressure cuts off blood flow to an area, causing inflammation and tissue death. An open sore is called a pressure ulcer. Pressure ulcers are categorized into six stages of tissue injury:

• Stage one
• Stage two
• Stage three
• Stage four
• Unstageable
• Deep tissue injury

Quick identification of altered skin integrity is essential to maintaining patient safety. The sooner a pressure injury is identified, the better the chances of treating it to prevent an advanced-stage pressure ulcer.

Who’s at Risk for Pressure Injuries?

Over 100 risk factors for pressure ulcers have been identified, with primary causes relating to poor circulation or impaired wound healing. Some populations are at a higher risk for pressure injuries due to factors like reduced skin elasticity, poor nutritional status, or impaired mobility. Examples of at-risk populations include:

• Elderly patients.
• People with diabetes.
• Individuals with impaired mobility (especially those with paraplegia or quadriplegia).
• Burn victims and other critically ill patients.
• Premature infants.

Whether a patient is in a long-term care facility or an acute care hospital, everyone should be treated as if they’re at risk. Here’s how the incidence rates of pressure ulcers vary by facility type:

• Acute care hospitals — 0.4-38%
• Long-term care facilities — 2.3-23.9%
• Home health — 0-17%

How to Incorporate the Braden Scale Assessment Tool

Braden scoring can be integrated into a flowsheet within an organization’s electronic documentation system. This allows nurses to quantify a patient’s risk and take appropriate actions based on the results.

A nurse scores a patient for each category, and the total score indicates the patient’s risk for pressure injury. Subsection categories of the Braden score scale include:

To implement the tool, facilities must obtain licensing through HD Nursing, which owns the licensing and educational tools for the Braden Scale. Licensing is available for hospitals/acute care facilities, long-term care facilities, and home health/hospice.

How to Develop an Implementation Program

Now that you understand the importance of skin assessment and staging, you’re probably looking to incorporate the Braden Scale into your team’s clinical practice. You can develop a plan for educating your staff and introducing the scale by following these steps:

1. Involve the Entire Team

Make the adoption of the scale a multidisciplinary team effort. Clinicians throughout your organization — nurses, physicians, CNAs, and the wound care team — will need to be familiar with its use and implications for patient care.

2. Create Policies and Procedures to Support Use

Incorporate the scoring tool into your facility’s pressure ulcer prevention or skin care policy, being sure to identify the desired frequency of assessment and documentation. Clearly identify the interventions that should be made based on score results. Identify how concerns will be added to the patient’s plan of care and establish a process for notifying the physician and obtaining an order for wound care services.

3. Develop a Training Program to Educate Staff

Before implementation of the tool, be sure to educate your team about the scale, including supporting policies, expected interventions, and documentation requirements. In addition to your unit educator, “Unit Champions” can spread education while also fielding any questions or concerns about the tool. Education efforts should be ongoing and must be revisited after the scale has been in use for some time, since there may be new issues or questions to address.

4. Incentivize Adoption Through a Recognition Program

Celebrate acceptance of the new workflow with staff rewards. Creativity counts, and rewards don’t have to be expensive to hold value. For example, a potluck celebration or drawing for a staff member to select a holiday off from work might be appreciated.

5. Audit Use

Collect patient outcomes data to demonstrate the effectiveness of the scale. Be sure to collect all findings and motivate staff in a way that is non-punitive to support a culture of safety. Create reports for auditing use and utilize the results to recognize and acknowledge improvements. Celebrate every success — even the little ones.

More Ways to Prevent Pressure Ulcers

Braden scores can be used in conjunction with organizational policies to reduce the risk of pressure injuries. Here are some ways to prevent patient harm in addition to using the tool.

Pressure Ulcer Prevention Policy

Nurses are required to document a patient’s skin integrity as part of a head-to-toe assessment on admission and at least once a shift. They may be required to document skin checks and interventions more frequently, depending on the patient’s risk. Their assessments, along with Braden scoring, prompt nurses to implement pressure ulcer prevention (PUP) strategies. Facilities may utilize a PUP bundle, which includes guidelines like:

• Frequent skin checks.
• Applying skin barrier creams.
• Moisture management (such as reducing sweating, oral secretions, or managing urinary incontinence).
• Floating bony prominences.
• Use of pressure-reducing mattresses.
• Repositioning every 2 hours in bed or every 15 minutes in a chair.

If a pressure injury is identified, the facility should provide guidelines for addressing the wound, such as a wound staging protocol, pressure injury reporting system, and consultation of a wound care nurse.

Equipment

Healthcare facilities can invest in equipment that reduces the risk of pressure injuries and aids mobility, such as pressure reduction mattresses or Hoyer lifts. They can also customize policies to include the appropriate type of mattress to use based on a patient’s Braden score. Certain healthcare settings may qualify for durable medical equipment coverage to support patients.

Adequate Staffing

PUP bundles can only be effective when nurses have the necessary tools and resources to carry them out. That’s why it’s so important to have enough nursing staff. Heavy nursing workloads restrict the amount of time nurses can spend with patients, which reduces their ability to follow through with frequent turns and skin checks. Short-staffing can also be a barrier to care for patients who require the assistance of multiple staff members for repositioning.

Braden Scale Assessment: FAQs

Answers to the following questions about Braden scores and how they can be used to improve outcomes at your facility will help you better understand this important assessment tool.

How frequently should patients or long-term care residents be assessed for pressure ulcers?

Checking a patient’s susceptibility to pressure ulcers should be an ongoing process, but what does this mean in practical terms? HD Nursing, the organization that licenses the Braden Scale to facilities, recommends assessing acute care patients:

• Upon admission
• During a nursing assessment and as needed throughout the shift
• When there is a change in patient condition that warrants an assessment

The Annals of Long-Term Care provides additional guidance for post-acute care residents, suggesting assessments for all new admissions, and:

• Upon either a deterioration or improvement in cognition or physical health.
• Every week for 4 weeks (then monthly or quarterly) for LTC residents.

Are there other risks for developing pressure injuries, not covered by the Braden Scale?

Yes. It’s important to note that the tool is intended to be used in tandem with clinical judgment, not in place of it. The nurse should still be alert to individual risks and changes in the patient’s condition that would warrant assessment and intervention.

The scale does not gauge the risk of developing a medical device-related pressure injury. These soft tissue injuries are the result of pressure caused by medical devices, equipment, or furniture that comes in contact with the person’s skin. It’s important to note that the Braden QD Scale accounts for medical devices, but is only applicable to pediatric patients.

For example, a person might have a high Braden score, indicating a low risk, but if they’re wearing a nasal cannula for oxygen, they’re at an increased risk for acquiring a medical device-related pressure injury. The nurse must assess this patient’s skin regularly, paying particular attention to the area behind the ears. Foam padding can be added to the tubing to help cushion the skin.

Other high-risk medical devices include:

• TED hose
• Ventilator tubing
• Feeding tubes
• Foley catheter tubing
• Restraints
• Bedpans

My facility has started using the Braden Scale, but the team feels like it’s just another box to check. How do I, as the nurse manager, encourage staff to use the tool?

Showing the value of the scale is a great starting place. Many staff members feel overwhelmed by the amount of documentation they’re required to do, and your team will be much more likely to use the scale if they know why it’s important as a preventative measure.

Pressure injuries result in longer lengths of stay, lower quality of life, and increased mortality and morbidity. Not only that, but the treatment of pressure injuries costs the U.S. $26.8 billion per year. Your patients and budgets are directly impacted by this issue.

Peer-to-peer support is a particularly effective way to encourage the adoption of new tools and processes. Consider launching a unit-based council or shared governance committee focused on pressure ulcer prevention to further engage your team.

As always, it’s important to talk to your team about the barriers they’re facing in using the new tool. Perhaps there’s a workflow issue that needs to be fixed or a concern that your team wants to address. Be curious, ask questions, and stay open to feedback.

Find More Ways to Improve Quality of Care

Utilizing the Braden Scale is just one cost-effective way to prevent patient harm, adding an extra layer of security to improve your quality of care and reduce facility costs. Looking for additional insights? Discover more ways to optimize patient outcomes at your facility by following along in IntelyCare’s free newsletter.