Introducing the Braden Q

An Evidence Based Tool for Identifying Pediatric Patients at

Risk for Pressure Ulcers

Pressure Ulcers Are:• A key indicator of nursing

care– Pressure Ulcers are

considered preventable with good nursing care – A NEVER event

• Rates are shared with the public

• Rates are used to compare the quality of nursing between hospitals

A pressure ulcer is• From the National Pressure Ulcer Advisory

Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP):– A pressure ulcer is localized injury to the skin and/or

underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear.

• The classification system:• Stage I – Nonblanchable erythema

Stage II – Partial-thickness skin loss Stage III – Full-thickness skin lossStage IV – Full-thickness tissue lossDeep Tissue Injury – Depth unknownUnstageable – Depth unknown

Stage 1 Pressure Ulcer

• Reddened• Does not blanch• Indicates lack of blood

flow and nutrients to the tissue

• Area at risk for tissue breakdown

• Need to reposition whatever is causing the pressure

• Difficult to detect in darker skin

Stage 2 Pressure Ulcer• Partial skin thickness disruption of

epidermis and/or dermis• Abrasion, blister, crater• Shallow, reddish pink wound bed• May lead to infection, possible hair

loss, scarring and other complications

Stage 3

• A full thickness skin loss including subcutaneous tissue.

Stage 4• Full thickness• Exposed bone,

tendon, or muscle. • Osteomyelitis is a

risk• Slough or eschar

may be present, as may undermining and tunneling.

Deep Tissue Injury• Deep maroon/purple

color• Indicates deep

subcutaneous injury occurring from the inside out.

• Despite the relatively mild appearance, these lesions can open up into full-blown pressure ulcers within days.

• Deep tissue injury usually advances rapidly despite of proper care

Unstageable• Full-thickness tissue loss• Depth of the ulcer is

completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.

• Eschar on the heels serves as "the body's natural (biological) cover" and should not be removed

The Goal is ZERO

• To reach the goal involves:– Using an evidence based tool to identify

patients at risk for skin breakdown– Implementing appropriate interventions for

patients found to be at risk

Introducing the Braden Q• Complete for all ages:

– On admission– Daily (day shift)– Transfer by receiving unit

• Location of the scale:– Admission flowsheet– 2J and 3J: Interventions flow sheet– PICU: A/I #2

• Due Task Beacon– Currently not programmed for due task

• NICU (NSRAS)– Using a skin assessment tool specific for infants– If pulled/float there, ask how to complete it

Mobility• Ability to change and control body positions

– 1. Completely immobile• Does not make even slight changes in body or extremity

position without assistance– 2. Very limited

• Makes occasional slight changes in body or extremity position but unable to completely turn self independently

– 3. Slightly limited• Makes frequent though slight changes in body or extremity

position independently– 4. No limitations

• Makes major and frequent changes in position without assistance

Activity• Degree of physical activity

• Do not confuse with mobility. A patient onbedrest is scored 1 even if he is mobile in bedand receives a 4 under mobility

– 1. Bedfast• Confined to bed

– 2. Chairfast• Ability to walk severely limited or non-existent. Cannot bear own

weight/must be assisted to chair– 3. Walks occasionally

• Very short distances with or without assistance; spends majority of each shift in bed or chair

– 4. All patients too young to ambulate OR walks frequently• Walks outside room at least BID and inside room at least

q 2 hr while awake

Sensory Perception• Ability to respond in a developmentally appropriate

way to pressure related discomfort• Can you feel when you are uncomfortable and shift/move?

– 1.Completely limited• Unresponsive to painful stimuli due to diminished level of

consciousness or sedation OR limited ability to feel pain over most of body surface

– 2. Very limited• Responds only to painful stimuli. Cannot communicate discomfort

except by moaning or restlessness OR has sensory impairment which limits the ability to feel pain or discomfort in 1 or 2 extremities

– 3. Slightly limited• Responds to verbal commands but cannot always communicate

discomfort or need to be turned OR has sensory impairment which limits the ability to feel pain or discomfort in 1 or 2 extremities.

– 4. No impairment• Responds to verbal commands. Has no sensory deficit, which limits

ability to feel or communicate pain or discomfort

Moisture• Degree to which a patient’s

skin is exposed to moisture.– 1. Constantly moist

• Skin is kept moist almost constantly by perspiration, urine, drainage, etc. Dampness is detected every time patient is moved or turned

– 2. Very moist• Skin is occasionally moist requiring

linen change every 8 hr– 3. Occasionally moist

• Skin is occasionally moist requiring linen change every 12 hr

– 4. Rarely moist• Skin is usually dry, routine diaper

changes. Linen only requires changing every 24 hr

Friction/Shear• Rubbing or sliding

• Friction: When skin moves against support surfaces• Shear: When skin and adjacent bony surface slide

across one another– 1. Significant Problem

• Spasticity, contracture, itching or agitation leads to almost constant thrashing and friction

– 2. Problem• Requires moderate to maximum assistance in moving.

Complete lifting without sliding against sheets is impossible. Frequently slides down in bed/chair requiring repositioning with maximum assistance

– 3. 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 relative good position in chair or bed most of the time but occasionally slides down

– 4. No apparent problem• Able to completely lift patient during a position change.

Moves in bed and chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.

NutritionUsual food intake pattern– 1. Very poor

• NPO &/Or maintained on clear fluids, or IVs for > 5 days OR albumin < 2.5 gm/dl OR never eats a complete meal. Rarely eats more than ½ of any food/feeding offered. Protein intake is only 2 servings of meat or dairy products per day. Takes fluids poorly. Does not take a liquid dietary supplement.

– 2. Inadequate• Is on liquid diet/tube feeding/TPN which provides inadequate

calories and minerals for age OR albumin < 3.0 gm/dl OR rarely eats a complete meal and generally eats only about ½ of any food/feeding offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement

– 3. Adequate • Is on tube feeding/TPN which provide adequate calories and

minerals for age OR eats over ½ of most meals/feedings. Eats total of 4 servings of meat/dairy products per day. Consumes supplements if ordered.

– 4. Excellent• Is on a normal diet providing adequate calories for age. Does

not require supplementation. Usually eats total of 4 or more servings of meat/dairy. Occasionally eats between meals. Does not require supplementation.

Tissue Perfusion and Oxygenation

• Determined by BP/Oxygen Saturation/Hemoglobin/Perfusion

1. Extremely compromised– Hypotensive (MAP < 50 mmHG; < 40 mmHG newborn) OR

patient does not physiologically tolerate position changes2. Compromised

– Normotensive. Serum pH < 7.4; Oxygen sat may be < 95 % OR Hgb may be < 10.0 gm/dl OR cap refill may be > 2 seconds.

3. Adequate– Normotensive. Normal Serum pH. Oxygen sat may be < 95 %

OR Hgb may be < 10.0 gm/dl OR cap refill may be > 2 seconds.

4. Excellent– Normotensive. Oxygen saturation > 95%; normal Hgb; cap

refill < 2 sec

Using the Braden QMary is a 16 year old female

admitted yesterday s/p Spinal Fusion. Use the following information from her orders and from nursing assessment to complete the Braden Q

• T= 36.8, Pulse= 110, RR= 24, BP= 118/72

• On continuous pulse ox- sats at 97%

• Morphine PCA with basal rate –pushes prior to any movement

• D5 ½ 20k at maintenance • Bed rest • Turn Q2hrs with assistance x2 staff

members• Sit at 90 degrees TID• NPO• Foley to straight drain• Interacts appropriately with family

and staff• Dressing over incision dry and

intact

Mobility for Mary• Open the DETAILS box!!• Look at the row description• Mary:

– 2 staff members to turn her– Bedrest– Sit at 90 degrees TID

• Her score is a 2– Based on a score of 3, 2, or 1 interventions will automatically cascade

Mobility Continued• Interventions automatically cascade:

– Use the details button to get row descriptors and additional information about each item until you are very familiar with each intervention

Z-flo

Activity for Mary• Mary:

– 2 staff members to turn her– Bedrest– Sit at 90 degrees TID

• Cascades for score of 3, 2, 1:– Activity Assistance– Transfer Device

Activity scores of 3, 2, 1 Cascades: Activity Assistance and Transfer Device

Sensory• Mary can communicate pressure related

discomfort and ask for help moving

Sensory Perception

• For a score of 3, 2, or 1… “minimize pressure”cascades.

Moisture

Mary’s skin is not exposed to moisture. If a score of 3, 2, or 1, then skin fold care and incontinence associated dermatitis would cascade.

Friction-Shear• Mary

– Bed rest – Turn Q2hrs with assistance x2 staff members– Sit at 90 degrees TID

Friction - ShearInterventions…..• Maxi Slides should be used to turn Mary• Z-flos can be used to prevent sliding down in bed• Mepilex may be used to pad elbows or heels if rubbing on sheets

– For some patients (other than Mary in this example) a sacral border dressing may be applicable – chart in a comment for now (new charting values for the molnycke products has been requested)

• Aquaphilic lotion to moisturize skin

Nutrition• Mary is NPO

Feeding cascades for 3, 2, 1 (unless already present in the routine peds group

Perfusion/oxygenation

• Mary:– BP 118/72– Saturation 97%

• No interventions auto-add under perfusion/oxygenation. – May want to collaborate with LIP to improve compromised perfusion and

oxygenation such as RBC transfusion, correction of altered pH, oxygen administration, etc.

Total Score• Total score

– Some idea of overall risk for pressure ulcer development– No additional interventions are added based on the total score

• Interventions come from each subscale score only

Infant scenario – How would you score this?Jaden is a 2 month old Down’s Syndrome infant with cardiac disease

VS: 37.2, 168, 62, 83/58

Oximetry 82%

Cap Refill 3-4 seconds

IV for antibiotics

Poor PO feeding; NG feedings q 3 hrs started; getting 50% of caloric needs

Frequent vomiting

I and O

Receiving blanket damp when moving patient

Occasionally in infants seat and need repositioning due to sliding down in the seat

Weak post-op; floppy tone

Mobility – Are Infants Mobile?

This infant would be a 2 or 3; If infant unable to roll over, they will never be a 4

Mobility Automatic Cascades – Bed Surfaces

• Use Details Box!

• Z-floisn’t a surface

Mobility Automatically Cascades: Heel Suspension and Turn Q2

What would you chart under “Activity” for an infant?

Score of 4: All patients too young to ambulate

How would you score “sensory perception”of an infant?

In our case study a 2 or 3 would be appropriate. Infants would never receive a 4.

Sensory Perception scores of 3, 2, 1: Cascades Minimize Pressure

• Pressure under IV hubs, oximeter probes, BP cuffs, etc. are our biggest source of pressure ulcers.

• Reposition devices• Place mepiform, mepitel, mepilex under devices

How would you score “Moisture” for this infant?

Score of 4 = Routine Diaper ChangesScore of 2 = Very moist, skin often moist, every 12 hour linen changesScore of 1 = Dampness detected every time patient moved or turned

****This patient would probably be a 1 or 2

Moisture scores of 3, 2, 1 Cascade: Skin Fold Care & Incontinence Associated Dermatitis

Cascades under Incontinence Associated Dermatitis

We are hoping to get more peds specific interventions here such as moisture barrier cream, cloth underpads, disposable washcloths

What score would you assign to “Friction and Shear” ?

***A score of 3 would be appropriate

Friction and Shear scores of 3, 2, 1: Cascade “minimize friction” and “transfer device”

We hope to have mepilex, scaral border dressing, mepiform, mepitel added as values here

What would you score “nutrition”?Infant Jaden: Poor PO feeding; NG feeding q 3h; 50% of caloric needs

*** Score of 2 would be correct

Nutrition score of 3, 2, 1 cascades “Feeding”

Note: For 2J and 3J… Feeding is already in the Interventions Flowsheet under Peds Routine Care so will not be added again.

How would you score “Perfusion/Oxygenation” for this 2 month old (oximetry 82%; cap refill 3-4 sec; BP 83/58)?

*** Score: Probably a 3. No pH is available; 82% sat is baseline for child so adequate

*** Nothing cascades under perfusion/oxygenation. May consider discussing RBC transfusion, oxygen, etc. with LIP and document under “clinician communication”

Total Score “18”: No further interventions cascade based on the total score

Interventions cascade based on subscales only

For more information about Wound and Skin

Contact your unit STAR

Look at the website: Go to Weblinks, click on Departments Sites, click on Wound/Skin Resource link

Related to Braden Q • Please ask if you have any questions• Report any issues/problems/suggestions

– this is new to our hospital and ALL of us so your ideas to make it better are appreciated!

Laura Phearman – pager 4239Deb Bruene – pager 7603Tracy Clapp – pager 5567Tiffany Phillips - pager 6493Mandi Houston – pager 5493Mardeana Deroo- pager 5211Aleta Porcella (nursing informatics) - pager 2017

Recognition and thanks to Bev Folkedahl for use of some slides and clip art for this presentation

Review Test

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