This document discusses validating the use of individual subscale scores from the Braden Scale for pressure ulcer risk assessment rather than just the cumulative score. It provides opinions from staff that the current use of the Braden Scale and Skin Bundle focuses more on documentation than interventions. The document recommends enhancing the Braden Scale in the EPIC electronic health record to flag low individual subscale scores and provide specific intervention recommendations tailored to each subscale. Examples are provided for interventions aimed at low friction/shear and nutrition subscale scores. Overall, the goal is to improve pressure ulcer prevention by guiding intervention selection based on assessment of individual risk factors.

1. Validation of Braden
Sub Scale Scores
Whitney Olson, Elizabeth Stefely, Tessa Swenson

2. Current Practice
• “If Braden Score (for ages
greater than 8 years) is 19-23 or
Braden Q score (for ages 8
years or less) is 17-28 skin will
be reassessed at a minimum
every 24 hours. When Braden
Score is 18 or less, Braden Q
Score is 16 or less or skin
assessment is abnormal, skin
will be assessed every 8 to 12
hours”-SCH Skin Assessment,
Prediction, and Prevention
Policy
• Frequency of assessment is
based on cumulative score,
rather than individual sub
scores.

3. Skin Bundle
• Foundation started with Skin Bundle. However, improvement is needed.

4. Staff Opinions
• “Just more charting work”.
• “Typically pick what is already being done, rather than
using it for ideas of possible interventions to improve
scores”.
• “Some-what reflects the Braden, but could be improved”.
• “It’s useful for some of the population on Peds. We don’t
use it in the NICU”.
• For some of the Peds population it’s silly because they
are kids that aren’t really in bed much. They are up
playing and walking around a lot of the time”.

5. Sub Scale Scores
• According to Gadd (2014), a patient could benefit
more from implementing interventions based on
an individual subscale score rather than the
cumulative Braden Scale score.
• Cox (2012), believes that in order to precisely
measure pressure sore risk, modification of
Braden Scale is needed. The six categories of the
Braden Scale were assessed individually and
recommendations for interventions were found to
improve sub scale scores.

6. Recommendations
• Develop a new method in EPIC that will allow low subscale
scores to be flagged.
• The low subscale scores could be flagged with a red
exclamation point, such as other abnormal results in EPIC.
• When the low subscale scores are flagged, the nurse
would be guided in EPIC through appropriate interventions
or consults to be ordered.
• Skin Bundle should be revised to tailor interventions toward
the six Braden sub scores versus Skin Bundle categories.
• Policy should be revised, requiring assessment of low sub
scale scores every shift.

7. Recommendations
Continued
• Interventions would be specific to the subscales
of, sensory perception, moisture, activity, mobility,
nutrition, and friction and shear.
• When Braden sub score has improved, provide
option to discontinue orders and interventions.
• By enhancing the Braden Scale in EPIC, it could
provide guidance for implementing interventions,
enhancing documentation, and improving patient
outcomes.

8. Friction and Shear

9. Example One: Friction and
Shear
• Interventions to reduce
• Do not raise HOB greater than 30 degrees (Lippoldt, 2014)
• Use a lift, rather than ‘boosting’ a patient
• If a lift is unavailable, use disposable glide sheets (Cox, 2011)
• Teach patients to move in bed using their hands and arms, rather than
their elbows and heels (Avent, 2012)
• Avoid skin-to-skin contact. Pad skin surfaces that may rub together.
• Provide preventative measures, such as transparent films,
hydrocolloids, or skin sealants. Develop criteria for use of preventative
dressings.
• Recommendations for EPIC
• Pop-up box of interventions for low scores
• Ordering of preventative measures

10. Example Two: Nutrition
• Interventions to improve
• Assess nutrition status of all admitting patients. (Dorner and Thomas, 2009)
• Ability for the patient to eat independently should be assessed, as well as
the adequacy of total nutrient intake.
• Enhanced foods and/or oral supplements should be provided between
meals, if needed.
• Provide adequate protein intake.
• Provide and encourage adequate daily fluid intake. Monitor for signs and
symptoms of dehydration.
• Encourage consumption of a balanced diet
• Recommendations for EPIC
• Pop-up box of interventions
• Dietitian consult
• Ordering of enhanced foods/oral supplements
• Teaching guides

11. References
• Armour-Burton, T., Field, W., Outlaw, L., Deleon., E. (2013). The healthy skin project:
changing nursing practice to prevent and treat hospital-aquired pressure ulcers. American
Association of Critical-Care Nurses, 33(3), 32-39. doi:
http://dx.doi.org/10.4037/ccn2013290
• Avent, Y. (2012). wound wise. Steer clear of friction, shear, and excess moisture. Nursing Made
Incredibly Easy, 10(6), 5-8. doi:10.1097/01.NME.0000420371.77458.de
• Barrett, R., Brown, K., Bergstrom, N., Horn, S., Li, J., Omolayo, T., Rapp, M. (2013).
Construct validity of the moisture subscale of the Braden Scale for predicting pressure
sore risk. Advances in Skin & Wound Care, 26(3), 122–127. doi:
10.1097/01.ASW.0000427921.74379.c5
• Beddoe, E., A., & Menella, H. (2014). Support surface mattress and/or overlay. Nursing
Practice and Skill. Rertived from: CINAHL
• Cox, Jill. (2012). Predictive power of the Braden Scale for pressure sore risk in adult critical care
patients. Journal of Wound, Ostomy, and Continence Nursing, 39(6), 613-621. Retrieved
from: MEDLINE .
• Dorner, B., Posthauer, M., & Thomas, D. (2009). From the NPUAP. The role of nutrition in
pressure ulcer prevention and treatment: National Pressure Ulcer Advisory Panel white
paper. Advances In Skin & Wound Care, 22(5), 212-221.
doi:10.1097/01.ASW.0000350838.11854.0a

12. References
• Gadd, M. (2014). Braden scale cumulative score versus subscale scores. Journal
of Wound, Ostomy, and Continence Nursing, 41(1), 86-89. Retrieved from:
MEDLINE
• Kallman, U., Bergstrand, S., Engstrom, M., Lindberg, L-G., & Lindgren A. (2013).
Different lying positions and thier effects on tissue blood flow and skin
temperature in older adult patients. Journal of Advanced Nurisng, 69(1), 133-
144. doi: 10.1111/j.1365-2648.2012.06000.x
• Lippoldt, J., Pernicka, E., & Staudinger, T. (2014). Interface pressure at different
degrees of backrest elevation with various types of pressure-redistribution
surfaces. American Journal of Critical Care, 23(2), 119-126. doi:
http://dx.doi.org/10.4037/ajcc2014670
• Neilson, J. (2014). Using a national guideline to prevent and manage pressure
ulcers. Nursing Management, 21(2), 18-21. Retrieved from: MEDLINE
• Sibbald, G. R., Goodman, L., Nortan, L., Krasner, D. L., & Ayello, E. A. (2012).
Prevention and treatment of pressure ulcers. Skin Therapy Letter. 17(8):4-7.
Retrieved from: CINAHL