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General Policy Manual
NYGH
SUBJECT:
POLICY & PROCEDURE
NUMBER:
II-210
BRADEN SCALE
CROSS REFERENCE:
AUTHORIZATION:
DATE ISSUED: July, 2006
DATE REVIEWED:
DATE REVISED: November, 2006
Page 1 of 5
POLICY:
Patients admitted to the hospital will undergo an initial skin assessment using the Braden
Scale for Predicting Pressure Sore Risk by nursing staff within 24 hours of admission
and/or upon transfer from another unit, every Tuesday thereafter and/or with any changes
in the patient’s condition.
Patients with identified risk factor(s) on the Braden Scale and/or a total Braden score equal
to or less than 16 will have a documented interdisciplinary care plan using the Skin
Integrity Guidelines.
Nursing staff will document on the Wound Assessment Tool any identified open wound(s)
on admission, upon transfer from another unit, and with each dressing change. Wound(s)
measurements to be completed and documented on the Wound Assessment Tool every
Tuesday, Friday and with any changes in the patient’s condition (e.g. debridement); except
for VAC therapy (e.g. every Monday, Wednesday & Friday).
PROCEDURE:
Assessment
1. Complete a head to toe skin assessment for any potential and actual compromise in
skin integrity using the Braden Scale for Predicting Pressure Sore Risk.
2. Using the Braden Scale for Predicting Pressure Sore Risk, choose one number
for each parameter that applies to the patient’s condition. Total the numbers to
determine the risk score.
3. Identify cause(s) and contributing factors such as friction, shear, pressure,
malnutrition, dehydration, trauma, immobility, medications, disease, and
moisture/incontinence.
4. Develop and implement an interdisciplinary plan of care to manage contributing
factors for pressure ulcers using the Skin Integrity Guidelines.
5. If wound(s) is identified, document using the Wound Assessment Tool.
General Policy Manual
NYGH
SUBJECT:
POLICY & PROCEDURE
NUMBER:
II-210
BRADEN SCALE
CROSS REFERENCE:
AUTHORIZATION:
DATE ISSUED: July, 2006
DATE REVIEWED:
DATE REVISED: November, 2006
Page 2 of 5