A nurse is completing a risk assessment on a new admission. Which standardized scale will the nurse use to calculate the client’s risk for pressure ulcers?
A.
Morse Scale
B.
Braden Scale
C.
Bristol Scale
D.
Hendrich II scale
The Correct answer and Explanation is:
The correct answer is B. Braden Scale.
The Braden Scale is a widely recognized and standardized tool used by healthcare professionals to assess a patient’s risk of developing pressure ulcers. It focuses on six key factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each of these factors is scored on a scale, and the cumulative score helps determine the level of risk a patient has for developing pressure ulcers.
- Sensory Perception: This assesses the patient’s ability to respond to discomfort. A lower score indicates a higher risk since patients who cannot feel discomfort may not reposition themselves to relieve pressure.
- Moisture: This factor evaluates the degree to which the skin is exposed to moisture, which can lead to maceration and increase the risk of skin breakdown.
- Activity: This measures the patient’s physical activity level. Those who are immobile or have limited mobility are at a higher risk.
- Mobility: Similar to activity, this factor assesses how well a patient can change and control their position. Limited mobility contributes to pressure buildup.
- Nutrition: Poor nutritional status can impair skin integrity and healing. A lower score in this category indicates a higher risk.
- Friction and Shear: This measures the risk posed by external forces that can cause skin damage, particularly in immobile patients.
The cumulative score from these factors ranges from 6 to 23, with lower scores indicating a higher risk of developing pressure ulcers. For example, a score of 15 or lower typically indicates that the patient is at moderate to high risk, warranting preventive measures.
In contrast, the Morse Scale is primarily used for fall risk assessment, the Bristol Scale assesses stool consistency, and the Hendrich II Scale evaluates fall risk among older adults. Therefore, the Braden Scale is specifically designed for assessing pressure ulcer risk, making it the correct choice for this scenario.