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Source:

Nursing2015

September 2011, Volume 41 Number 9 , p 67 - 67

Authors

  • Suzanne M. Creehan BSN, RN, CWON
  • Tod C. Brindle BSN, RN, ET, CWOCN

Abstract

THE BRADEN SCALE for pressure ulcer risk assessment is used worldwide, but translating those numbers into nursing interventions can be challenging for busy nurses.1 This article describes our color-coded "stoplight" approach to the Braden Scale, and shows how focusing on subcategory scores may be more -important than focusing on the total risk score.The Braden Scale is a valid and reliable tool for assessing a patient's risk for pressure ulcers, based on deficits in patient mobility, activity, moisture level, nutrition, sensory perception, and friction and shear. Nurses assign numeric scores of 1 to 4 in each category, with the exception of the friction and shear category, where patients are assigned a score of 1 to 3, and then tally the results to gauge pressure ulcer risk. A score of 18 or less indicates risk of pressure ulcer development and the need for escalating interventions.1But how many times are staff -recording a number in their documentation yet failing to enact interventions

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