skin

Recommended Skin Treatment Protocol Per Braden Score

The Braden scale helps to identify patients at risk for pressure ulcers
(also termed decubitus ulcers or bedsores).
The protocol corresponding to each degree of risk comprises the recommended nursing care to mitigate that risk.

Criteria

  • Moisture (1–4)
  • Sensory perception (1–4)
  • Activity (1–4)
  • Mobility (1–4)
  • Nutrition (1–4)
  • Friction and shear (b)

Risk Score: 9 or below

Very High Risk

Recommended Skin Treatment Protocol
Per the Braden Skin Risk Assessment

  • frequent turning
  • maximal remobilization
  • protect heels
  • manage moisture, nutrition, friction, shear
  • pressure-reduction support surface
  • use foam wedges for 30° lateral positioning
  • supplement with small shifts
  • use pressure-relieving surface if…
    • patient has intractable pain or…
    • severe pain exacerbated by turning or…
    • additional risk factors

Risk Score: 10 to 12

High Risk

Recommended Skin Treatment Protocol
Per the Braden Skin Risk Assessment

  • increase frequency of turning
  • supplement with small shifts
  • pressure reduction support surface
  • use foam wedges for 30° lateral positioning
  • maximal remobilization
  • protect heels
  • manage moisture, nutrition, friction, shear

Risk Score: 13 to 14

Moderate Risk

Recommended Skin Treatment Protocol
Per the Braden Skin Risk Assessment

  • turning schedule
  • use foam wedges for 30° lateral positioning
  • pressure-reduction support surface
  • maximal remobilization
  • protect heels
  • manage moisture, nutrition, friction, shear

Risk Score: 15 to 18

At Risk

Recommended Skin Treatment Protocol
Per the Braden Skin Risk Assessment

  • frequent turning
  • maximal remobilization
  • protect heels
  • manage moisture, nutrition, friction, shear
  • pressure-reduction support surface

Risk Score: 19+

Low Or No Risk