1. DUHS Skin/Wound Management Council
4/15/2017
Learning Best Practice Skin Care Pressure Ulcer Risk Assessment: Using The Braden Q Scale Effectively
DUHS Skin/Wound Management Council
July 2012

2. Learning Best Practice Skin Care
4/15/2017
Learning Best Practice Skin Care
This activity discusses best bedside practices related to pressure ulcer prevention and optimal skin care. The following modules will prepare you to provide the best care possible for your patient:
Etiology & prevention of Pressure Ulcers
Using The Braden Scale Effectively
Using The Braden Q Scale Effectively
Advanced skin care (perineal dermatitis)
Tissue Load Management
Nutrition & wound healing
Wound Assessment
Dressings (not all topical therapy)
Wound Documentation

3. 4/15/2017
Objectives:
This is the third of 9 modules designed to prepare you for optimal patient care. After completing this learning activity, you will be able to:
Use Braden Q Scale correctly
Discuss examples of how the Braden Q Scale may be used effectively

4. One of the most important principles of care includes:
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The NPUAP/EPUAP & WOCN Society published national guidelines for the prevention of pressure ulcers. These guidelines are based on available research and expert opinion.
One of the most important principles of care includes:
Identifying Those At Risk
This standard recommends that a risk assessment scale should be completed on all patients
< 7 years old
at admission & daily.

5. The Braden Q Risk Assessment Scale . . .
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The Braden Q Risk Assessment Scale . . .
Is used for pediatric patients ≤ 7 years of age to determine risk for pressure ulcer development.
Helps guide overall prevention strategies.
Is completed on admission then, once daily.
Is used to score patient’s risk For a score ≤ 16 – implement the Pressure Ulcer Prevention/Treatment Plan of Care.
. A Braden score of 16 or less requires the implementation of the Pressure Ulcer Prevention and Treatment Plan of Care.

6. There Are 7 Subscales Within The Braden Q Scale . . .
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Mobility
Activity
There Are 7 Subscales Within The Braden Q Scale . . .
Sensory Perception
Each assesses one area known to contribute to the development of a pressure ulcer
Each individual subscale can then be used to target interventions for the patient
You will score the patient in each of the 7 areas then total numbers to score patient’s risk
Moisture
Friction & Shear
Nutrition
Tissue Perfusion and Oxygenation

7. Three of the Subscales Within The Braden Q Scale . . .
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Mobility
Activity
Three of the Subscales Within The Braden Q Scale . . .
Sensory Perception
Are the same as those with Braden Scale
Mobility
Activity
Sensory Perception
Each subscales is scored just as the Braden scale. Return to Module 2 if you need a review.

8. Three of the Subscales Within The Braden Q Scale . . .
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Mobility
Activity
Three of the Subscales Within The Braden Q Scale . . .
Sensory Perception
Moisture
Have same titles but use different criteria to score subscale
Moisture
Friction and Shear
Nutrition
Friction & Shear
Nutrition

9. One of the Subscales Within The Braden Q Scale . . .
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Mobility
Activity
One of the Subscales Within The Braden Q Scale . . .
Sensory Perception
Scores an area of additional risk for pediatric patient
Tissue Perfusion and Oxygenation
This is a completely new subscale
Moisture
Friction & Shear
Nutrition
Tissue Perfusion and Oxygenation

10. Now, let’s review the differences for Braden Q Assessment Scale
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Now, let’s review the differences for Braden Q Assessment Scale

11. Score the patient as “1” if:
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Moisture
The degree to which the patient’s skin is exposed to moisture
Score the patient as “1” if:
Constantly Moist:
Skin is kept moist almost constantly by perspiration, urine, etc
Dampness is detected every time patient is moved or turned

12. The degree to which the patient’s skin is exposed to moisture
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Moisture
The degree to which the patient’s skin is exposed to moisture
Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.
Score the patient as “2” if:
2. Very Moist:
Skin is often, but not always, moist
Linen is changed at least every 8 hours

13. Moisture 3. Occasionally Moist: Score the patient as “3” if:
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Moisture
The degree to which the patient’s skin is exposed to moisture
Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.
Very moist: Skin is often, but not always, moist. Linen is changed at least every 8 hours.
Score the patient as “3” if:
3. Occasionally Moist:
Skin is occasionally moist, requiring an extra linen change every 12 hours

14. Moisture 4. Rarely Moist: Score the patient as “4” if:
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Moisture
The degree to which the patient’s skin is exposed to moisture
Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.
Very moist: Skin is often, but not always, moist. Linen is changed at least once a shift.
Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day.
Score the patient as “4” if:
4. Rarely Moist:
Skin is usually dry
Routine diaper changes
Linen only requires changing every 12 hours

15. Score the patient as “1” if:
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Nutrition
This is the patient’s Usual food intake pattern Scoring this areas requires that you know something about food intake prior to admission. Problematic with trauma or post surgical patients.
Score the patient as “1” if:
1. Very Poor: This patient:
Is NPO and/or maintained on clear liquids, or IVs for more than 5 days OR albumin < 2.5 mg/dl OR never eats complete meal
Rarely eats more than 1/2 of any food offered
Eats 2 servings or less of protein (meat or dairy products) per day
Takes fluids poorly
Does not take a liquid dietary supplement

16. Score the patient as “2” if:
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Nutrition
This is the patient’s Usual food intake pattern
Very Poor.
Score the patient as “2” if:
2. Inadequate: This patient:
Is on liquid diet or tube feeding/TPN, which provides inadequate calories and minerals for age OR albumin < 3 mg/dl OR rarely eats a complete meal & generally eats only about ½ of any food offered
Has a protein intake that includes only servings of meat or dairy products per day
Occasionally will take a dietary supplement

17. Nutrition 3. Adequate: This patient:
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Nutrition
This is the patient’s Usual food intake pattern
Very Poor
Inadequate.
Score the patient as “3” if:
3. Adequate: This patient:
Is on a tube feeding or TPN regimen which provides adequate calories and minerals for age OR eats over half of most meals.
Eats a total of 4 servings of protein (meat, dairy products) each day
Occasionally will refuse a meal, but will usually take a supplement if offered

18. Nutrition This is the patient’s Usual food intake pattern
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Nutrition
This is the patient’s Usual food intake pattern
Very Poor
Inadequate
Adequate
Score the patient as “4” if:
4. Excellent: This patient is on a normal diet providing adequate calories for age. For Example:
Eats most of every meal
Never refuses a meal
Usually eats a total of 4 or more servings of meat & dairy products
Occasionally eats between meals
Does not require supplementation

19. Score the patient as “1” if:
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Friction & Shear
Score the patient as “1” if:
1. Significant Problem: This patient:
Has spasticity, contractures, itching or agitation leading to almost constant thrashing and friction

20. Score the patient as “2” if:
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Friction & Shear
Significant Problem: Spasticity, contractures, itching or agitation leads to almost constant thrashing and friction. .
Score the patient as “2” if:
2. Problem: This patient:
Requires moderate to maximum assistance on moving
Complete lifting without sliding against the sheets is impossible
Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance

21. Score the patient as “3” if:
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Friction & Shear
Significant Problem: Spasticity, contractures, itching or agitation leads to almost constant thrashing and friction.
Problem: Requires moderate to maximum assistance on moving. Complete lifting without sliding against the sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance.
Score the patient as “3” if:
3. Potential Problem: This patient:
Moves feebly or requires minimum assistance
During a move, has skin that probably slides to some extent against sheets, chair, restraints, or other devices
Maintains relatively good body position in chair or bed most of the time but occasionally slides down

22. Score the patient as “4” if:
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Friction & Shear
Significant Problem: Spasticity, contractures, itching or agitation leads to almost constant thrashing and friction.
Problem: Requires moderate to maximum assistance on moving. Complete lifting without sliding against the sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance.
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 relatively good body position in chair or bed most of the time but occasionally slides down
Score the patient as “4” if:
4. No Apparent Problem: This patient:
Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move
Maintains good body position in bed or chair at all times

23. The patient’s degree of physical activity
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Activity
The patient’s degree of physical activity
Score the patient as “1” if:
1. Bedfast: This patient is confined to bed.

24. The patient’s degree of physical activity
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Activity
The patient’s degree of physical activity
Bedfast: Confined to bed
Score the patient as “2” if:
2. Chair Fast: This patient:
Is severely limited or non-existent in their ability to walk
Cannot bear own weight and/or must be assisted into chair or wheelchair

25. The patient’s degree of physical activity
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Activity
The patient’s degree of physical activity
Bedfast: Confined to bed
Chair fast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.
Score the patient as “3” if:
3. Walks Occasionally: This patient:
Walks occasionally during the day, but for very short distances, with or without assistance
Spends majority of each shift in bed or chair

26. The patient’s degree of physical activity
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Activity
The patient’s degree of physical activity
Bedfast: Confined to bed
Chair fast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.
Walks occasionally: walks occasionally during the day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.
Score the patient as “4” if:
4. Walks Frequently: This patient walks outside the room at least twice a day and inside the room at least once every 2 hours during waking hours. This includes:
All patients too young to ambulate
Any patient who developmentally would not be expected to walk

27. Tissue Perfusion and Oxygenation
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Tissue Perfusion and Oxygenation
This subscale is a completely new addition
Score the patient as “1” if:
1. Extremely Compromised: This patient :
Is hypotensive (MAP <50mmHg; < 40 in a newborn)
Does not physiologically tolerate position changes

28. Tissue Perfusion and Oxygenation
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Tissue Perfusion and Oxygenation
Extremely compromised: hypotensive (MAP <50mmHg; < 40 in a newborn) or the patient does not physiologically tolerate position changes.
Score the patient as “2” if:
2. Compromised: This patient:
Is normotensive
Has oxygen saturation < 95% or hemoglobin may be < 10 mg/dl or capillary refill > 2 seconds
Has serum pH < 7.40

29. Tissue Perfusion and Oxygenation
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Tissue Perfusion and Oxygenation
Extremely compromised: hypotensive (MAP <50mmHg; < 40 in a newborn) or the patient does not physiologically tolerate position changes.
Compromised: Normotensive; oxygen saturation may be < 95% or hemoglobin may be < 10 mg/dl or capillary refill may be > 2 seconds; Serum pH is < 7.40.
Score the patient as “3” if:
3. Adequate: This patient:
Is normotensive
Has oxygen saturation < 95% or hemoglobin < 10 mg/dl or capillary refill > 2 seconds
Has normal serum pH

30. Tissue Perfusion and Oxygenation
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Tissue Perfusion and Oxygenation
Extremely compromised: hypotensive (MAP <50mmHg; < 40 in a newborn) or the patient does not physiologically tolerate position changes.
Compromised: Normotensive; oxygen saturation < 95% or hemoglobin < 10 mg/dl or capillary refill > 2 seconds; Serum pH is < 7.40.
Adequate: Normotensive; oxygen saturation < 95% or hemoglobin < 10 mg/dl or capillary refill > 2 seconds; Serum pH is normal.
Score the patient as “4” if:
4. Excellent: This patient:
Is normotensive
Has oxygen saturation > 95% or normal hemoglobin and capillary refill < 2 seconds

31. 4/15/2017
Now that you know how to score a patient, let’s see the Braden Q Scale in action!!
July 2012

32. What Is Her Braden Q Score?
4/15/2017
Little Orphan Annie . . .
. . . Is a 1 month old noted prenatally to have a left hypoplastic heart defect. She is now 20 days post op but remains vented. The report from previous shift indicates that she:
Is sedated and moving arms feebly to painful stimuli only
Can not be completely lifted off sheets with repositioning
Has frequent diarrhea with diaper changes with every turn
Is receiving tube feeding but not at goal rate
Has a MAP < 50mmhg
Has O2 sat 92% and pH 7.32
What Is Her Braden Q Score?

33. Annie’s Braden Q Score Total Braden Q Score is: 15 Mobility 2 Activity
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Subscale
Score
Rationale
Mobility 2
Not able turn without assist
Activity 4
Developmentally, she does not walk
Sensory Perception
Moves to painful stimuli only
Moisture 1
Has frequent diaper changes
Friction & Shear
Unable to completely lift with position changes
Nutrition
Receiving tube feedings not at goal rate
Tissue Perfusion & Oxygenation
O2 sat < 95% and pH < 7.32
Total Braden Q Score is: 15
A pressure ulcer prevention plan of care is indicated

34. 4/15/2017
Dora the Explorer
After a restless night at home, 7 year old Dora was admitted for evaluation of flu symptoms. She has been hospitalized for the past 2 weeks in PICU. Report from previous shift indicates that she:
Is alert or responsive. Trying to get out to bed to explore. She gets out of bed to the chair frequently.
Most recent blood gas shows an O2 sat 99% & pH with normal vital signs
Is taking all of her meals
Is continent of bowel and bladder

35. Dora’s Braden Q Score Total Braden Q Score is: 25 Subscale Score
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Subscale
Score
Rationale
Mobility 4
Able to move herself in bed
Activity 3
In chair frequently
Sensory Perception
Alert and responsive
Moisture
Continent of bowel & bladder
Friction & Shear
Moves self
Nutrition
Eating all meals
Tissue Perfusion & Oxygenation 2
All WNL
Total Braden Q Score is: 25
A pressure ulcer prevention plan of care is not indicated

36. 4/15/2017
Congratulations! You have completed your review of Module 3 Click the next button to test yourself on the details

37. 4/15/2017
Skin_Risk_Assess_BQ