BRADEN SCALE: Identifying Risk and Prevention of Pressure Ulcers

The Braden Scale for predicting pressure sore risk is a cornerstone in clinical nursing, legal accountability, and evidence-based patient care. Its development, global recognition underscores its importance in preventing pressure ulcers.

The Braden Score is one of several prediction scoring system being used within the NHS.  In a previous blog post the Waterlow score was considered. 

This brief blog post offers an exploration of the Braden Score, including its history, application, legal implications, and a practical case example.

OUR VIDEO ON THE BRADEN SCALE THAT PROVIDES MORE INFORMATION!

Historical Context and Development: Evolution of the Braden Scale

Originating from a Robert Wood Johnson Teaching Nursing Home project, the Braden Scale was rigorously tested for reliability and validity, with its findings published in 'Nursing Research' in 1987. Further studies refined the tool, leading to the establishment of Prevention Plus by Barbara Braden and Nancy Bergstrom in 1998, which provides resources for pressure ulcer prevention.

Global Impact

The Braden Scale's effectiveness is recognised worldwide, with translations in multiple languages and validations across various healthcare settings, affirming its superior reliability and validity compared to other tools.

Calculation and Usage of the Braden Score

The Braden Scale assesses six key criteria, each contributing to the overall risk of pressure ulcer development:

Sensory Perception	Ability to respond to discomfort or pressure-related pain
Moisture	Degree of skin exposure to moisture
Activity	Level of physical activity
Mobility	Ability to change and control body positions
Nutrition	Adequacy of nutritional intake
Friction and Shear	Potential for skin damage from movement against a surface

Each criterion is scored on a scale, typically from 1 (worst) to 4 (best), except for 'Friction and Shear', which is scored from 1 to 3. The total score can range from 6 (high risk of pressure ulcer development) to 23 (low risk).

A lower total score indicates a higher risk.

How the Score is Used

In practice, the Braden Score guides clinicians in developing individualised care plans determinate upon the identified level of pressure injury risk.  Following calculation of the score the local policy should then be considered and applied. 

Scores 15 to 18	signal mild risk and warrant standard prevention measures
Scores 13 to 14	indicate moderate risk, necessitating increased frequency of repositioning and other interventions
Scores 10 to 12	represent high risk, prompting more intensive prevention strategies
Scores 9	or below suggest very high risk, often requiring advanced care, such as specialised mattresses and comprehensive skin care protocols

Clinical Relevance of the Braden Score

The six criteria of the Braden Scale are integral to assessing a patient's risk for pressure ulcer development, each addressing a specific aspect of patient health and risk factors. This assessment is a critical component of the patient care process, informing the preventative measures that need to be taken to mitigate risk.

Legal Perspectives: Standard of Care and Liability

The Braden Score serves as a benchmark in legal scenarios, defining the risk and in application of the local policy setting out the standard of ‘reasonable’ care. Inadequate assessment or documentation can lead to allegations of negligence (Bolam, Bolitho). 

Documentation and Litigation

Documentation of the Braden Score is essential in legal cases or complaints. This documentation can prove vital in demonstrating that comprehensive assessments were conducted, and robust care plans were produced and enacted.

Case Example: Application in Practice

Mrs. Smith, a 78-year-old woman with diabetes and reduced mobility, was admitted to a healthcare facility. Using the Braden Scale, the nursing team assessed her risk and implemented a comprehensive and robust care plan, including regular repositioning, specialist surfaces (bed and chair), mobility, dietary and hydration monitoring, continence aids, and careful monitoring (skin inspections).  This proactive approach effectively prevented pressure ulcers, demonstrating the practical application and importance of the Braden Score in healthcare. The condition of Mrs Smith’s skin was monitored with regular skin inspections and the care plan was amended as and when her condition changed (in line with the local policy and nursing judgement).  The Braden Score allowed for a standardised process to be followed and the level of risk to be communicated.

Conclusion

The Braden Score is integral to patient care, with its calculation and application critical in both preventing pressure ulcers.  The Braden Score, in combination with the local policy, allows for identified risk to be mitigated and pressure injury to be prevented.  As with any healthcare aid and scoring system the Braden Score is merely a tool and should never replace nursing and medical judgement. 

Author

Scott Harding-Lister

Scott is a qualified nurse and solicitor. He was a senior nurse within the NHS before leaving to pursue a career as a solicitor in City practices. In 2013 he set up Apex Health Associates and the expert witness practice has gone from strength to strength. Scott is a medico-legal expert, a nursing expert, and head of practice at Apex.