Braden Scales for Pressure Injury Risk Assessment

Pressure injury (PrI) risk assessment seeks to identify a patient’s modifiable and nonmodifiable risk factors. Once a patient is determined to be at risk for a PrI, consider the identified risk factors when developing the patient’s individualized prevention plan,1 as well as both low subscale scores and the total risk assessment scale score. Ideally, the PrI prevention care plan should be developed with input from the patient and the patient’s family. However, it is beyond the scope of this article to discuss prevention strategies; the authors refer interested readers to the 2019 International Guideline for more information.1 Pressure injury risk assessment is a multifaceted systematic process. Skin assessment incorporates visual and tactile clues to look for indications of pressure damage via: (a) skin color changes from the person’s usual skin tone,2 (b) vulnerable tissue from previously healed PrI scars, and (c) inspecting for the presence of medical devices or other objects that may cause pressure. Risk assessment also includes evaluating any individual patient characteristics known to be risk factors (eg, patient comorbidities) that are not specifically captured on risk assessment scales/instruments. All of these multidimensional components, including assessment with a validated risk assessment scale, are used by the clinician to make a clinical decision about patient PrI risk. RISK ASSESSMENT SCALES Validated risk assessment scales have been used in clinical practice for decades. The following section provides a concise overview of the four Braden Risk Assessment Scales. Braden Scale for Predicting Pressure Sore Risk The first of the Braden Risk assessment scales is the Braden Scale for Predicting Pressure Sore Risk. Most clinicians refer to it simply as “the Braden Scale.” It is a research-based instrument from a conceptual schema developed and copyrighted by two visionary American nurses, Drs. Barbara Braden and Nancy Bergstrom. First published in 1987,3–5 it scores six risk factors: sensory/perception, moisture, activity, mobility, nutrition, and friction/shear (see Table). The Braden Scale is used for patients ages 8 to 100 plus years old. There is substantial research to support its validity and reliability.4–8 Lyder and colleagues provided data that the Braden Scale is valid in diverse skin tones, including Black and Latino/Hispanic adults.9 The Braden Scale has been widely used in North America and globally. Table. - COMMONLY USED BRADEN PRESSURE INJURY RISK ASSESSMENT SCALES Scale Characteristics Braden Scale 3–9 Braden Scale II 10–11 Braden Q Scale 12–14 Braden QD Scale 15–17 Population Children and adults, ≥ 8 y Children and adults, ≥ 8 y Children between 21 d and 8 y old Children and young adults from preterm infants to 21 y old No. of risk factors 6 6 7 7 Factors to assess - Sensory/perception- Moisture- Activity- Mobility- Nutrition- Friction/shear - Sensory/perception- Moisture- Activity- Mobility- Nutrition- Friction/shear - Sensory/perception- Moisture- Activity- Mobility- Nutrition- Friction/shear- Tissue perfusion/oxygenation - Mobility- Sensory/perception- Friction/shear- Nutrition- Tissue perfusion/oxygenation- No. of medical devices- Repositionability/skinprotection Scoring 15–18 = Mild risk13–14 = Moderate risk10–12 = High risk<9 = Severe Risk 15–18 = Mild risk13–14 = Moderate risk10–12 = High risk<9 = Severe Risk 25 = Low risk21 = Medium risk<16 = At risk for PrI ≥13 = At risk Note: This table is adapted from a previous, larger table of risk assessment scales.© Delmore & Ayello 2023. Braden Scale II In April 2021, Health Sense Ai, a subsidiary of HD Nursing, secured the copyright to the Braden Scale. They updated the scale and renamed the revised instrument the Braden Scale II.10 Drs Braden and Bergstrom worked with the Health Sense Ai team to update the language on the Braden Scale II, including using the term “pressure injury” rather than “pressure sore.” To obtain permission to use the Braden Scale II, you must complete the license use forms and pay a fee on their website (www.bradenscale.com). In addition to English, the Braden Scale II is currently available in French and Spanish. The revised scale has the same six risk assessment factors as the original Braden Scale, which is important to retain the reliability and validity of the scale. Within each of the six subsections, descriptions were updated to facilitate user scoring accuracy of the scale. There is a glossary of terms to which license holders have access. Health Sense Ai/HD Nursing also offers a variety of resources contained in the Braden Scale II toolkit that educate clinicians about the scale. The toolkit includes case examples, a glossary of terms, a scoring guide, and a training module. This package for license holders helps train staff in the correct use of the scale. Score interpretation for the Braden Scale and Braden II Lower subscale numbers indicate higher risk, which need to be addressed in the patient’s PrI prevention care plan regardless of the overall scale score. In the original Braden and Braden II scales, the scores for each of the six factors are added to obtain an overall score, which ranges from 6 (highest risk) to 18 (at risk). A total score of 19 to 23 indicates that the patient is not at risk. The cut-off scores for overall risk and the levels of risk for each subscale are the same for both instruments.11 Braden Scale or Braden Scale II According to Dr Hester of Health Sense Ai/HD Nursing, Clinicians should use the Braden Scale version that their provider is currently licensed for and has approval to use in their electronic health record (EHR). For now, those facilities can continue to use the original Braden Scale in their work setting. Since accurate prediction is the foundation to effective PrI programs, HD Nursing does not plan to license the Braden II directly to EHRs but is licensing directly to providers. This allows providers access to scoring guides and training materials and support that helps ensure correct use of the tool.11 See the HD website for further information. NEONATAL AND PEDIATRIC RISK ASSESSMENT SCALES Braden Q Scale Drs Quigley and Curley adapted the Braden Scale to create the Braden Q Scale for use in neonatal and pediatric populations (gestational age of 21 days up to age 8 years).12,13 They added an additional subscale, tissue perfusion/oxygenation, to the same six risk factors in the Braden Scale. Over the years, researchers have assessed the Braden Q Scale and determined it to be reliable and valid.14 Risk for PrI is based on the total Braden Q score, which ranges from 7 (highest risk) to 28 (lowest risk); scores of 16 or below indicate that the patient is at risk of developing a PrI (see Table). Braden QD Scale The Braden QD Scale is based on the Braden Q. It was created by Curley and colleagues,15 and copyright is currently held by Dr Curley. The Braden QD is available in 11 languages (English, Chinese, Danish, Finnish, French [Canada], French [Geneve], Italian, Korean, Portuguese, Thai, and Turkish) and PDF files can be downloaded from Dr Curley’s website.16 The website also has a training video and self-learning module. The Braden QD is designed for use for patients from preterm to 21 years old. In addition to including five of the six items from the Braden Q Scale (mobility, sensory perception, friction/shear, nutrition, tissue perfusion/oxygenation), the Braden QD Scale also includes the number of medical devices and repositionability/skin protection. The latter two items specifically address medical devices (see Table). In this population, a total score of 13 or higher indicates PrI risk.16,17 BEYOND RISK ASSESSMENT SCALES It is important to remember that validated risk assessment scales are only a part of a comprehensive assessment for PrI risk. Some other potential risk factors that are important to consider (age, comorbidities, acuity, surgery)18,19 are discussed below. Age Clinicians should evaluate the impact that age may have on a person’s intrinsic risk for PrI.18,19 Newborns’ skin is vulnerable because of its immaturity. Persons 65 years or older may have skin frailty resulting from physiologic changes such as dryness, decreased elasticity from epidermal thinning, and loss of adipose tissue, which can diminish the skin’s protective function. Comorbidities Risk assessment should include evaluating the person’s disease burden, including obesity and malnutrition.18–21 The 2019 International Guideline underscores the importance of considering obesity in your patient’s PrI risk assessment.21 Patients with low or high body mass indices may both be at greater risk for PrI development. Similarly, inadequate nutrition is a significant PrI risk factor.20 Surgery Length A patient’s time from admission to surgery and length of time in surgery may be markers of immobility and, thus, PrI risk.1 A person’s clinical status as ranked by the American Society of Anesthesiologists (ASA) Physical Status Classification may also be a marker of a patient’s PrI risk.18 Providers should consider all three factors risk factors for a person undergoing surgery. Medical Device Use Critically ill patients need PrI risk assessment22,23 due in part to their illness and also because of the medical devices used in their treatment.24–26 Beyond medical devices, other objects may also cause device-related PrIs, such as items that a patient might lie on in their bed: needle or bottle cap covers, eyeglasses, tubing, and toys, among others.24–26 Medical devices are the most frequent etiology for PrI in neonates and children27 and one of the reasons why this factor is assessed on the Braden QD Scale.15–17 As of January 2023, neither the Braden Scale, Braden Scale II, nor Braden Q Scale include medical devices as a factor to evaluate. Research supports that medical-device-related pressure injuries (MDRPIs) occur an average of 3 days sooner than Prls from other etiologies.26 Therefore, staff should diligently assess patients who have medical devices.27 Raising awareness of MDRPI in adults is also important.1,25,26 The SORE mnemonic (S, Stock items; O, objects; R, Required medical devices; E, Electrical equipment) may be useful in alerting staff to equipment and other objects that may cause a MDRPI.25 Anatomic PrI Locations Specific anatomic areas may pose greater PrI risk. The following are key anatomic areas that are readily prone to PrI formation given the right circumstances. Heels Heel anatomy, limited tissue over the calcaneus, and foot position all contribute to making the heel vulnerable and at risk for PrIs.28–33 Data from two research studies29,30 provide evidence that patient comorbidities (eg, diabetes mellitus, vascular disease) along with immobility, are risk factors for developing heel PrIs and should be considered when assessing a person’s PrI risk. Clinicians can refer to a previously published heels algorithm on the importance of proper foot positioning (eg, avoid external rotation).31 Sacrum/coccyx/ischial tuberosities A patient’s skeletal morphology may be an intrinsic nonmodifiable risk for Prl.34 In addition, physical changes in persons with spinal cord injury may increase PrI risk, such as changes in the sacral and ischial area that lead to skeletal muscle atrophy, fat infiltration into muscles, bone shape loss leading to flattening of the tips of the ischial tuberosities, and thinning of the skin around the ischial tuberosities.35 In a study that evaluated patients with (n = 15) and without (n = 15) full-thickness sacrococcygeal PrIs, Delmore and colleagues34 found that patients with PrIs had different morphology and morphometry. This study also noted that PrIs were often located in the coccyx region. Risk Assessment and Technology Technology may provide other ways of assessing a persons’ risk for PrI. Research on skin temperature,36,37 subdermal moisture,38,39 and imaging40,41 may provide a more complete picture to the puzzle of PrI risk assessment. New technologies may also reduce cost.40 CONCLUSIONS Follow the directions/guidelines for use of a particular risk assessment scale and your institution’s policy for when to perform a PrI assessment. Additional research supports using a comprehensive assessment of the patient beyond a scale. Clinicians should consider PrI risk assessments as part of the usual standard of care along with skin assessments. When a patient is determined to be at risk, implement care plans and prevention strategies to avoid a PrI from occurring if possible, or prevent a PrI from deteriorating. Not all PrIs may be preventable, so clinicians are encouraged to consult the literature on the issue of avoidable and unavoidable PrIs.42–45