Description

The Braden Scale Assessing Risk: The Braden Scale evaluates 6 factors: Sensory Perception Ability to respond to pressure-related discomfort Moisture Degree of skin exposure to moisture Activity Degree of physical activity Mobility Ability to change and control body position Nutrition Usual food intake pattern Friction & Shear Movement against surfaces Braden Score Interpretation: 1923 No Risk 1518 Mild Risk 1314 Moderate Risk 1012 High Risk 9 Very High Risk Staging of Pressure Ulcers: Stage 1 Non-blanchable redness of intact skin Stage 2 Partial thickness skin loss (shallow open ulcer) Stage 3 Full thickness skin loss (subcutaneous tissue visible) Stage 4 Full thickness tissue loss (bone, tendon, or muscle exposed) Evidence-Based Prevention Strategies: Repositioning Every 2 hours for bed-bound patients / Every 1 hour for chair-bound Skin Assessment Head-to-toe on admission and every shift Moisture Management Keep skin clean and dry