Braden tool

Reference: Developed by Zulkowski, Ayello, and Berlowitz Used with permission. Instructions: This tool includes examples of interventions that may be considered for specific scores on each Braden subscale, along with the nurse and Certified Nursing Assistant CNA responsibilities for care provision. These should be tailored to meet the needs of your patient and used as examples of how all levels of unit staff have responsibilities for pressure ulcer prevention.

Background: This is an example of an education booklet that can be handed out to patients at-risk for pressure ulcers and their families. Background: This tool can be used to determine who will be responsible for each of the tasks identified in your bundle of best practices for preventing pressure ulcers. One way to generate interest and buy-in from the staff is to ask them to self-assign their responsibilities from a prioritized list of tasks that need to be accomplished.

Instructions: Complete the table by entering the different best practices and the specific individuals who will be responsible for completing each task.

Use: Use this tool to assign and clarify the roles and responsibilities of each staff member. Background: This table gives an example of how responsibilities may be assigned among different staff members. Background: The purpose of this tool is to assess current staff education practices and to facilitate the integration of new knowledge on pressure ulcer prevention into existing or new practices. Instructions: Complete the form by checking the response that best describes your facility.

Use: Identify areas for improvement and develop educational programs where they are missing. Does your facility have initial and ongoing education on pressure ulcer prevention and management for both nursing and nonnursing staff?

If no, this is an area for improvement. Does your facility's education program for pressure ulcer prevention and management include the following components? What areas of knowledge does the assessment of staff suggest need more attention in education? Internet Citation: Section 7. Tools and Resources continued.

Content last reviewed October Browse Topics. Topics A-Z. Quality and Disparities Report Latest available findings on quality of and access to health care. Notice of Funding Opportunities. Preventing Pressure Ulcers in Hospitals Section 7. Previous Page. Next Page. Are we ready for this change? How will we manage change?

What are the best practices in pressure ulcer prevention that we want to use? How do we implement best practices in our organization? How do we measure our pressure ulcer rates and practices? How do we sustain the redesigned prevention practices? Tools and Resources. Skin Temperature Most clinicians use the back rather than the palm of their hand to assess the temperature of a patient's skin.

Remember that increased skin temperature can be a sign of fever or impending skin problems such as a Stage I pressure ulcer or a diabetic foot about to ulcerate. Touch the skin to evaluate if it is warm or cool. Compare symmetrical body parts for differences in skin temperature. Skin Color Ensure that there is adequate light. Use an additional light source such as a penlight to illuminate hard to see skin areas such as the heels or sacrum.

Know the person's normal skin tone so that you can evaluate changes. Look for differences in color between comparable body parts, such as left and right leg. Depress any discolored areas to see if they are blanchable or nonblanchable.

Look for redness or darker skin tone, which indicate infection or increased pressure. Look for paleness, flushing, or cyanosis. Remember that changes in coloration may be particularly difficult to see in darkly pigmented skin. Skin Moisture Touch the skin to see if the skin is wet or dry, or has the right balance of moisture.

Remember that dry skin, or xerosis, may also appear scaly or lighter in color. Check if the skin is oily. Note that macerated skin from too much moisture may also appear lighter or feel soft or boggy. Also look for water droplets on the skin.

Is the skin clammy? Determine whether these changes localized or generalized. Skin Turgor To assess skin turgor, take your fingers and "pinch" the skin near the clavicle or the forearm so that the skin lifts up from the underlying structure. Then let the skin go. If the skin quickly returns to place, this is a normal skin turgor finding. If the skin does not return to place, but stays up, this is called "tenting," and is an abnormal skin turgor finding.

Poor skin turgor is sometimes found in persons who are older, dehydrated, or edematous, or have connective tissue disease. Skin Integrity Look to see if the skin is intact without any cracks or openings. Determine whether the skin is thick or thin. Identify signs of pruritis, such as excoriations from scratching. Determine whether any lesions are raised or flat.

Identify whether the skin is bruised. Note any disruptions in the skin. If a skin disruption is found, the type of skin injury will need to be identified.

Since there are many different etiologies of skin wounds and ulcers, differential diagnosis of the skin problem will need to be determined. For example is it a skin tear, a pressure ulcer, or moisture-associated skin damage or injury?

Top of Page 3C: Pressure Ulcer Identification Notepad Background: Reporting of abnormal skin findings among nursing staff is critical for pressure ulcer prevention. Completely Limited: Unresponsive does not moan, flinch, or grasp to painful stimuli, due to diminished level of consciousness or sedation. OR limited ability to feel pain over most of body surface.

Very Limited: Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness. Slightly Limited: Responds to verbal commands, but cannot always communicate discomfort or need to be turned.

OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. No Impairment: Responds to verbal commands, has no sensory deficit which would limit ability to feel or voice pain or discomfort. Moisture degree to which skin is exposed to moisture 1. Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. Very Moist: Skin is often, but not always, moist. Linen must be changed at least once a shift.

Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day. Rarely Moist: Skin is usually dry, linen only requires changing at routine intervals. Activity degree of physical activity 1. Bedfast: Confined to bed. He has arm talent. Plus, his football I.

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The Gamecocks zeroed in on Davis in the spring and received his commitment on April Even with Carolina landing Rattler and Bailey, he never wavered. He has enrolled at Carolina and will participate in spring practice with the Gamecocks. He also is the No. Braden Scale is a n Evidence-Based.

Approach to Pressure Injury Prevention. PO Box Benton, AR Contact Us. Braden Scale and Braden II.