Question

how to assess braden score on a person. explain the steps

Answer 1

ANSWER:

BRADEN SCALE is used for detecting the risk of developing pressure ulcer.

The scoring of braden scale:

• 19 to 23 - not at risk
• 15 to 18 - preventative interventions
• 13 to 14 - moderate risk
• 10 to 12 - high risk
• 6 to 9 - very high risk

There are six categories such as,

1. Sensory perception
2. Moisture
3. Activity
4. Mobility
5. Nutrition
6. Friction / shear

SENSORY PERCEPTION:

• check the client's mobility.
• check the clients sensory perception by means of verbal commands.
• when the client responds your command the client had no impairment.
• When the client responds to the verbal command but felt slight discomfort means the client is slightly limited.
• When the client had painful stimuli and discomfort during communication the client is very limited
• when the client is unresponsive to the stimuli the client is completely limited.

MOISTURE:

• check the moisture by checking the clients skin.
• If the client had severe perspiration or passed urine always is categorized as constantly moist.
• If the client skin pattern is moist often but not always means he/she categorized as very moist.
• If the client linen is changed daily is categorized as occasionally moist.
• If the client is rarely moist that means the client is always dry.It is categorized as rarely moist.

ACTIVITY:

• check the client activity by monitoring the client.
• Categorize the client as frequent walking, occasional walking and bed ridden.

MOBILITY:

• If the client makes no changes in the body are completely immobile.
• If the client have any occasional changes in position comes under very limited mobility.
• If the client having frequent position changes comes under slightly limited.
• If the client having frequent changes without any assistance they are comes under no limitation.

NUTRITION:

• If the client consumes proper nutrition, does not require any supplements they are comes under excellent nutrition status.
• If the client eats well, but having some supplements are categorized as adequate nutrition status.
• If the client rarely eat the meals and receives less than optimum liquid diet are comes under probably inadequate nutrition.
• If the client never eats meal and in nil per oral status are comes under very poor nutrition status.

FRICTION AND SHEAR:

• if the client moves from bed and chair adequately, having sufficient muscle strength and maintaining good positioning are comes under no apparent problem.
• if the client moves freely but requires minimum assistance are comes under potential problem.
• if the client requires moderate to maximum need are comes under problem.