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Braden Scale
Availability
Please visit this website for the instrument: Braden Scale for Predicting Pressure Sore Risk
Classification
Exploratory: Spinal Cord Injury (SCI)
Short Description of Instrument
The Braden Scale for Predicting Pressure Sore Risk® was developed by Barbara Braden and Nancy Bergstrom.
The Braden Scale for Predicting Pressure Sore Risk is a clinically validated tool that allows nurses and other health care providers to reliably score a patient/client's level of risk for developing pressure ulcers. It measures functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure. Lower levels of functioning indicate higher levels of risk for pressure ulcer development.
The Braden Scale is a summated rating scale made up of six subscales scored from 1-4 (1 for low level of functioning and 4 for the highest level or no impairment). Total scores range from 6-23 (one subscale is scored with values of 1-3, only). The subscales measure functional capabilities of the patient that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure. A lower Braden Scale Score indicates lower levels of functioning and, therefore, higher levels of risk for pressure ulcer development.
Braden Scale: Subscales
  1. Sensory Perception
  2. Activity
  3. Mobility
  4. Skin Moisture
  5. Nutritional Intake
  6. Friction and Shear
Braden Scale: Total Risk Level
  1. At Risk (15-18)
  2. Moderate Risk (13-14)
  3. High Risk (10-12)
  4. Very High Risk (9 or below)
Rationale/Justification
Strengths/Weaknesses: The burden to administer the Braden Scale for both the clinician and individual with SCI is minimal. There is limited psychometric evidence (e.g., no reliability data) in SCI. No formal/standardized training in the public domain on how to accurately score each subcategory
i. Eyeballing the participant/subject
ii. Degree of participant/subject familiarity
iii. Clinical judgment is used to assign a score
Scoring
To accurately predict who will develop pressure ulcers for the purpose of planning effective preventive strategies.
Total score is used as a rough indicator of intensity of interventions. Subscale score helps orient staff to the bundle of preventive interventions required.
References
Bergstrom, N., Braden, B. J., Laguzza, A., & Holman, V. (1987). The Braden Scale for Predicting Pressure Sore Risk. Nurs Res, 36(4), 205-210.
 
Prevention Plus [Internet]. Omaha (NE): Prevention Plus; c2000, 2001. The Braden Scale; [cited 2018 Jun 11]. Available from: https://www.bradenscale.com/ Prevention Plus.
 
Bergstrom, N., Braden, B., Boynton, P.,& Bruch, S. (1995). Using a research-based assessment scale in clinical practice. Nurs Clin North Am, 30(3), 539-551.
 
Bergstrom, N.,& Braden, B. J. (2002). Predictive validity of the Braden Scale among Black and White subjects. Nurs Res, 51(6), 398-403.
 
Braden, B. J.,& Bergstrom, N. (1994). Predictive validity of the Braden Scale for pressure sore risk in a nursing home population. Res Nurs Health, 17(6), 459-470.
 
Lima-Serrano M, González-MÉndez MI, Martín-Castaño C, Alonso-Araujo I, Lima-Rodríguez JS. Predictive validity and reliability of the Braden scale for risk assessment of pressure ulcers in an intensive care unit. Med Intensiva. 2018;42(2):82-91.
 
Maklebust, J., Sieggreen, M. Y., Sidor, D., Gerlach, M. A., Bauer, C.,& Anderson, C. (2005). Computer-based testing of the Braden Scale for Predicting Pressure Sore Risk. Ostomy Wound Manage, 51(4), 40-42, 44, 46 passim.
 
Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, Alvarez-Nieto C. Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs. 2006;54(1):94-110.
 
Sadeghi Fazel F, Derakhshanrad N, Yekaninejad MS, Vosoughi F, Derakhshanrad A, Saberi H. Predictive Value of Braden Risk Factors in Pressure Ulcers of Outpatients with Spinal Cord Injury. Acta Med Iran. 2018;56(1):56-61.
 
VandenBosch, T., Montoye, C., Satwicz, M., Durkee-Leonard, K.,& Boylan-Lewis, B. (1996). Predictive validity of the Braden Scale and nurse perception in identifying pressure ulcer risk. Appl Nurs Res, 9(2), 80-86.