an article of Ana Arbones MainarBachelor of Pharmacy, Orthopedic Technician and owner of
In people with mobility problems, it is very important to prevent and treat pressure ulcers. The lack of sensitivity in some areas or the obligation to maintain certain positions for long periods of time causes the appearance of bedsores, something very annoying and painful for the patient.
That is why at ortoweb we always recommend prevention through creams, lotions, cushions, mattresses, postural systems, etc. And above all, making frequent postural changes.
The Braden scale helps us to make a correct assessment of the risk of pressure ulcers and take the necessary measures to plan and carry out treatment.
According to the sum of the points, the risk of pressure ulcer will be:
· Low if the result is between 23 – 20 points.
· Medium if the result is between 19 – 16 points.
· High if the result is between 15 – 11 points.
· Very high if the result is between 10 – 6 points.
SENSITIVITY – Ability to react and respond with complaints to pressure
Non-existent: 1 point
– There is no response to painful stimuli for possible reasons: Unconsciousness, sedation.
– Disorder of pain sensation due to paralysis, most of the body (for example, the height cross section).
Severely restricted: 2 points
– The reaction only occurs with strong stimuli for pain.
– Complaints are expressed with difficulty (for example only by moaning or restlessness).
– Disorder of the sensation of pain due to paralysis that affects part of the body.
A little restricted: 3 points
-Lack of response.
-Complaints cannot always be expressed (for example when a change of position is needed).
-Pain sensation disorder due to paralysis of one or two affected limbs.
No restrictions: 4 points
-There is a response to pain.
-Complaints are expressed.
-There is no interference from the sensation of pain.
MOISTURE – Extent to which the skin is exposed to moisture
Constantly wet: 1 point
– The skin is constantly wet with urine, sweat or feces.
– Every time the patient turns he is wet.
Often wet: 2 points
– The skin is often moist, but not always.
– The bed linen or that of the patient must be changed at least once per shift.
Sometimes wet: 3 points
-The skin is sometimes wet and once a day there is a need to wash and clean the patient.
Rarely wet: 4 points
– The skin is generally dry.
– There is rarely a need to wash the patient.
ACTIVITY – Measure of physical activity
Bedridden: 1 point
– Confined to bed.
Sitting: 2 points
– Can move but with the help of others.
– You cannot carry your own weight alone.
– You need help to sit up (bed, chair, wheelchair).
Walk little: 3 points
-During the day it moves alone but it does so rarely and only for short distances.
-Needs help over long distances.
-Spends most of the time in bed or in a chair.
Walk regularly: 4 points
-Regularly walks, walks, 2-3 times per shift.
-Moves regularly
MOBILITY – Ability to change position and maintain
Completely still: 1 point
-Can not move. Cannot change position without help.
Severely restricted mobility: 2 points
-Sometimes moves slightly (body or limbs)
-You can’t clean yourself.
Restricted mobility: 3 points
-Regularly makes small changes in the position of the body and extremities.
Mobility: 4 points
-You can change your own position.
NUTRITION – Nutritional habits
Very poor diet: 1 point
– Eat small portions no more 2/3
– Eat only 2 or less servings of protein (Dairy, fish, meat)
– Drinking too little.
– Do not supplement the diet.
– Or you cannot take an oral diet.
– Or only drink clear liquids.
– Or take or more infusions a day.
Moderate diet: 2 points
– Rarely eats a normal portion of food, usually about half of the food offered.
– Eat about 3 servings of protein
– Irregular intake of a dietary supplement.
– Or receives too few nutrients.
– Or tube feeding or infusion.
Adequate nutrition: 3 points
– Eat more than half of the normal portions of food.
– Take 4 servings of protein.
– From time to time he refuses to eat.
– He takes the food supplements himself.
– Or you can taste or consume most of the nutrients.
Good nutrition: 4 points
– He always eats what is offered to him.
– Takes 4 or more servings of protein himself
– Eat sometimes between meals
– You do not need a diet supplement.
FRICTION – Friction and shear
Existing problem: 1 point
– You need a lot of support points to change position.
– Self-lifting is not possible
– You have spastic contractures.
– Has spastic contractures
– He is very restless (sheets balled up)
Potential problem: 2 points
– Moves a little by himself or needs a little help.
– It can get up a bit on the sheets.
– You can spend a lot of time in a waiting position.
Not a problem at the moment: 3 points
– Moves only up from bed to chair.
– He has enough strength to be able to rise.
– Can maintain a holding position without slipping.
You can consult the extensive catalog of anti-decubitus material of Ortoweb .
About the author:
Ana Arbones Mainar
Ana Arbones Mainar She has a degree in Pharmacy from the University of Navarra, an Orthopedic Technician from the University of Barcelona, a Master’s in Pharmaceutical Care and a university expert in personalized drug dosing systems (SPD).
He is currently the owner of Farmacia Arbones Mainar where, in addition to direct patient care, SPDs are prepared and pharmacotherapeutic follow-up is carried out in residences and polymedicated patients who request it.
She also owns the company , the first online orthopedics in Spain, which for more than 10 years has been dedicated to improving the quality of life of all people with special needs. Specialists in mobility, wheelchairs, technical aids and anti-decubitus material.