Performing Braden Scale

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Standar Issued Day Acknowledgement by.
Operatin Director of Bali International Hospital
g
Procedur
e
dr. Sheira Aurani, MPH
(SOP)

Definition Is a standardized, evidence-based assessment tool commonly used in health care to assess and
document a patient’s risk for developing pressure injuries.

Objective As a reference for applicants to be used to predict the risk of developing a hospital or facility-acquired
pressure ulcer or injury.

Policy

Procedur 1. Assess for risk factors for pressure ulcer development and alter those factors, if possible.
e 2. Assess skin of the older adult frequently for the development of pressure ulcers. The Braden
Scale for Predicting Pressure Sore Risk is one of the most commonly used instruments for
predicting the development of pressure ulcers (www.bradenscale.com). The Braden Scale
assesses pressure ulcer risk in six areas: sensory perception, skin moisture, activity, mobility,
nutrition, and friction/shear.
3. Stage the ulcer so appropriate treatment can be started. The National Pressure Ulcer Advisory
Panel advocates the following staging system (see Figure 9-3).
a. Stage I—intact skin with nonblanchable redness of a localized area, usually over a bony
prominence.
b. Stage II—partial thickness loss of dermis presenting as a shallow open ulcer with a red–
pink wound bed, without slough; may also present as an intact or open/ruptured serum-
filled blister.
c. Stage III—full-thickness tissue loss, with subcutaneous fat that may be visible but bone,
tendon, or muscle is not exposed; may include undermining and tunneling. Slough may be
present but does not obscure the depth of tissue loss.
d. Stage IV—full-thickness tissue loss with exposed bone, tendon, or muscle; slough or
eschar may be present on some parts of the wound bed; often includes undermining and
tunneling.
e. Unstageable—full-thickness tissue loss in which the base of the ulcer is covered by slough
and/or eschar in the wound bed.
f. Suspected deep tissue injury—a localized area of intact skin or blood-filled blister, maroon
 Performing Braden Scale

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or purple in color, caused by damage of the underlying soft tissue from shear or pressure.
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Figure 9-3. International NPUAP/EPUAP pressure injury stages. (A) Stage I—nonblanchable
erythema. (B) Stage II—partial thickness skin loss with exposed dermis. (C) Stage III—fullthickness skin loss. (D) Stage IV—
full-thickness skin and tissue loss. (E) Unstageable pressure injury—obscured full thickness skin and tissue loss. (F) Deep
tissue pressure injury—persistent non-blanchable deep red, maroon, or purple discoloration. (2016 NPUAP Pressure Injury
Staging Illustrations from http://www.npuap.org/resources/educational-and-clinical-resources/pressureinjury- staging-
illustrations/. Used with permission of the National Pressure Ulcer Advisory Panel March 2018. © NPUAP.)

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