Learning Best Practice Skin Care Pressure Ulcer Risk Assessment: Using The Braden Q Scale Effectively

1. Learning Best Practice Skin CarePressure Ulcer Risk Assessment:Using The Braden Q Scale Effectively DUHS Skin/Wound Management Council

2. Learning Best Practice Skin Care This activity discusses best bedside practices related to pressure ulcer prevention and optimal skin care. The following modules will prepare you to provide the best care possible for your patient: • Etiology & prevention of Pressure Ulcers • Using The Braden Scale Effectively • Using The Braden Q Scale Effectively • Advanced skin care (perineal dermatitis) • Tissue Load Management • Nutrition & wound healing • Wound Assessment • Dressings (not all topical therapy) • Wound Documentation

3. Objectives: This is the third of 9 modules designed to prepare you for optimal patient care. After completing this learning activity, you will be able to: • Use Braden Q Scale correctly • Discuss examples of how the Braden Q Scale may be used effectively

4. The NPUAP/EPUAP & WOCN Society published national guidelines for the prevention of pressure ulcers. These guidelines are based on available research and expert opinion. One of the most important principles of care includes: Identifying Those At Risk This standard recommends that a risk assessment scale should be completed on all patients < 7 years old at admission & daily.

5. The Braden Q Risk Assessment Scale . . . • Is used for pediatric patients ≤ 7 years of age to determine risk for pressure ulcer development. • Helps guide overall prevention strategies. • Is completed on admission then, once daily. • Is used to score patient’s risk For a score ≤ 16 – implement the Pressure Ulcer Prevention/Treatment Plan of Care.

6. There Are 7 Subscales Within The Braden Q Scale . . . Mobility Activity • Each assesses one area known to contribute to the development of a pressure ulcer • Each individual subscale can then be used to target interventions for the patient • You will score the patient in each of the 7 areas then total numbers to score patient’s risk Sensory Perception Moisture Friction & Shear Nutrition Tissue Perfusion and Oxygenation

7. Three of the Subscales Within The Braden Q Scale . . . Mobility Activity • Are the same as those with Braden Scale • Mobility • Activity • Sensory Perception • Each subscales is scored just as the Braden scale. Return to Module 2 if you need a review. Sensory Perception

8. Three of the Subscales Within The Braden Q Scale . . . Mobility Activity • Have same titles but use different criteria to score subscale • Moisture • Friction and Shear • Nutrition Sensory Perception Moisture Friction & Shear Nutrition

9. One of the Subscales Within The Braden Q Scale . . . Mobility Activity • Scores an area of additional risk for pediatric patient • Tissue Perfusion and Oxygenation • This is a completely new subscale Sensory Perception Moisture Friction & Shear Nutrition Tissue Perfusion and Oxygenation

10. Now, let’s review the differences for Braden Q Assessment Scale

11. Moisture The degree to which the patient’s skin is exposed to moisture Score the patient as “1” if: • Constantly Moist: • Skin is kept moist almost constantly by perspiration, urine, etc • Dampness is detected every time patient is moved or turned

12. Moisture The degree to which the patient’s skin is exposed to moisture • Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. Score the patient as “2” if: 2. Very Moist: • Skin is often, but not always, moist • Linen is changed at least every 8 hours

13. Moisture The degree to which the patient’s skin is exposed to moisture • 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 is changed at least every 8 hours. Score the patient as “3” if: 3. Occasionally Moist: • Skin is occasionally moist, requiring an extra linen change every 12 hours

14. Moisture The degree to which the patient’s skin is exposed to moisture • 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 is changed at least once a shift. • Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day. Score the patient as “4” if: 4. Rarely Moist: • Skin is usually dry • Routine diaper changes • Linen only requires changing every 12 hours

15. Nutrition This is the patient’s Usual food intake pattern Scoring this areas requires that you know something about food intake prior to admission. Problematic with trauma or post surgical patients. Score the patient as “1” if: 1. Very Poor: This patient: • Is NPO and/or maintained on clear liquids, or IVs for more than 5 days OR albumin < 2.5 mg/dl OR never eats complete meal • Rarely eats more than 1/2 of any food offered • Eats 2 servings or less of protein (meat or dairy products) per day • Takes fluids poorly • Does not take a liquid dietary supplement

16. Nutrition This is the patient’s Usualfood intake pattern • Very Poor. Score the patient as “2” if: 2. Inadequate:This patient: • Is on liquid diet or tube feeding/TPN, which provides inadequate calories and minerals for age OR albumin < 3 mg/dl OR rarely eats a complete meal & generally eats only about ½ of any food offered • Has a protein intake that includes only 3 servings of meat or dairy products per day • Occasionally will take a dietary supplement

17. Nutrition This is the patient’s Usualfood intake pattern • Very Poor • Inadequate. Score the patient as “3” if: 3. Adequate:This patient: • Is on a tube feeding or TPN regimen which provides adequate calories and minerals for age OR eats over half of most meals. • Eats a total of 4 servings of protein (meat, dairy products) each day • Occasionally will refuse a meal, but will usually take a supplement if offered

18. Nutrition This is the patient’s Usualfood intake pattern • Very Poor • Inadequate • Adequate Score the patient as “4” if: 4. Excellent:This patient is on a normal diet providing adequate calories for age. For Example: • Eats most of every meal • Never refuses a meal • Usually eats a total of 4 or more servings of meat & dairy products • Occasionally eats between meals • Does not require supplementation

19. Friction & Shear Score the patient as “1” if: 1. Significant Problem:This patient: • Has spasticity, contractures, itching or agitation leading to almost constant thrashing and friction

20. Friction & Shear • Significant Problem: Spasticity, contractures, itching or agitation leads to almost constant thrashing and friction. . Score the patient as “2” if: 2. Problem: This patient: • Requires moderate to maximum assistance on moving • Complete lifting without sliding against the sheets is impossible • Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance

21. Friction & Shear • Significant Problem: Spasticity, contractures, itching or agitation leads to almost constant thrashing and friction. • Problem: Requires moderate to maximum assistance on moving. Complete lifting without sliding against the sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Score the patient as “3” if: 3. Potential Problem: This patient: • Moves feebly or requires minimum assistance • During a move, has skin that probably slides to some extent against sheets, chair, restraints, or other devices • Maintains relatively good body position in chair or bed most of the time but occasionally slides down

22. Friction & Shear • Significant Problem: Spasticity, contractures, itching or agitation leads to almost constant thrashing and friction. • Problem: Requires moderate to maximum assistance on moving. Complete lifting without sliding against the sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. • Potential Problem: Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good body position in chair or bed most of the time but occasionally slides down Score the patient as “4” if: 4. No Apparent Problem: This patient: • Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move • Maintains good body position in bed or chair at all times

23. Activity The patient’s degree of physical activity Score the patient as “1” if: 1. Bedfast:This patient is confined to bed.

24. Activity The patient’s degree of physical activity • Bedfast: Confined to bed Score the patient as “2” if: 2. Chair Fast:This patient: • Is severely limited or non-existent in their ability to walk • Cannot bear own weight and/or must be assisted into chair or wheelchair

25. Activity The patient’s degree of physical activity • Bedfast: Confined to bed • Chair fast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. Score the patient as “3” if: 3. Walks Occasionally:This patient: • Walks occasionally during the day, but for very short distances, with or without assistance • Spends majority of each shift in bed or chair

26. Activity The patient’s degree of physical activity • Bedfast: Confined to bed • Chair fast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. • Walks occasionally: walks occasionally during the day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair. Score the patient as “4” if: 4. Walks Frequently:This patient walks outside the room at least twice a day and inside the room at least once every 2 hours during waking hours. This includes: • All patients too young to ambulate • Any patient who developmentally would not be expected to walk

27. Tissue Perfusion and Oxygenation This subscale is a completely new addition Score the patient as “1” if: 1. Extremely Compromised:This patient : • Is hypotensive (MAP <50mmHg; < 40 in a newborn) • Does not physiologically tolerate position changes

28. Tissue Perfusion and Oxygenation • Extremely compromised:hypotensive (MAP <50mmHg; < 40 in a newborn) or the patient does not physiologically tolerate position changes. Score the patient as “2” if: 2. Compromised:This patient: • Is normotensive • Has oxygen saturation < 95% or hemoglobin may be < 10 mg/dl or capillary refill > 2 seconds • Has serum pH < 7.40

29. Tissue Perfusion and Oxygenation • Extremely compromised:hypotensive (MAP <50mmHg; < 40 in a newborn) or the patient does not physiologically tolerate position changes. • Compromised:Normotensive; oxygen saturation may be < 95% or hemoglobin may be < 10 mg/dl or capillary refill may be > 2 seconds; Serum pH is < 7.40. Score the patient as “3” if: 3. Adequate:This patient: • Is normotensive • Has oxygen saturation < 95% or hemoglobin < 10 mg/dl or capillary refill > 2 seconds • Has normal serum pH

30. Tissue Perfusion and Oxygenation • Extremely compromised: hypotensive (MAP <50mmHg; < 40 in a newborn) or the patient does not physiologically tolerate position changes. • Compromised: Normotensive; oxygen saturation < 95% or hemoglobin < 10 mg/dl or capillary refill > 2 seconds; Serum pH is < 7.40. • Adequate: Normotensive; oxygen saturation < 95% or hemoglobin < 10 mg/dl or capillary refill > 2 seconds; Serum pH is normal. Score the patient as “4” if: 4. Excellent:This patient: • Is normotensive • Has oxygen saturation > 95% or normal hemoglobin and capillary refill < 2 seconds

31. Now that you know how to score a patient, let’s see the Braden Q Scale in action!!

32. Little Orphan Annie . . . . . . Is a 1 month old noted prenatally to have a left hypoplastic heart defect. She is now 20 days post op but remains vented. The report from previous shift indicates that she: • Is sedated and moving arms feebly to painful stimuli only • Can not be completely lifted off sheets with repositioning • Has frequent diarrhea with diaper changes with every turn • Is receiving tube feeding but not at goal rate • Has a MAP < 50mmhg • Has O2 sat 92% and pH 7.32 What Is Her Braden Q Score?

33. Annie’s Braden Q Score

34. Dora the Explorer After a restless night at home, 7 year old Dora was admitted for evaluation of flu symptoms. She has been hospitalized for the past 2 weeks in PICU. Report from previous shift indicates that she: • Is alert or responsive. Trying to get out to bed to explore. She gets out of bed to the chair frequently. • Most recent blood gas shows an O2 sat 99% & pH 7.40 with normal vital signs • Is taking all of her meals • Is continent of bowel and bladder

35. Dora’s Braden Q Score

36. Congratulations!You have completed your review of Module 3 Click the next button to test yourself on the details

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