Braden Scale for Pressure Injury Risk

• Physical assessment techniques include maintaining privacy, preparing the environment, and uncovering only one body part at a time.
• Clinical photography, good lighting, and appropriate measuring tools are essential.
• Gloves should be used when coming into contact with body fluids or open skin.

Braden Scale

• The Braden Scale assesses the risk of developing pressure injuries.
• It was developed in 1987 by Barbara Braden and Nancy Bergstrom.
• It guides preventative interventions by identifying at-risk patients.
• Six categories are: sensory perception, moisture, activity, mobility, nutrition, friction, and shear.
• Sensory perception measures the ability to detect and respond to discomfort or pain.
• Moisture assesses the degree of skin moisture.
• Activity evaluates the level of physical activity.
• Mobility assesses the ability to adjust body position independently.
• Nutrition examines nutritional status.
• Friction and shear consider the impact of friction and shear forces on the skin.
• Scoring ranges from 1 to 4 for each category, except Friction and Shear, which is scored 1 to 3.
• Total scores range from 6 to 23, with higher scores indicating lower risk.
• No risk: 19-23
• Mild risk: 15-18
• Moderate risk: 13-14
• High risk: 10-12
• Severe risk: less than or equal to 9

ABCDE Assessment for Skin Cancer

• Asymmetry: Moles or spots that are not symmetrical.
• Border: Irregular, scalloped, or poorly defined borders.
• Color: Multiple colors or shades in the spots.
• Diameter: Spots Larger than 6 mm in diameter.
• Evolving/Evolution: Changes in size, shape, or color over time.

Expected vs Unexpected Findings: Skin Color and Temperature

• Hyperpigmentation: Increased melanin in one area (birthmarks, sun damage, pregnancy changes).
• Hypopigmentation: Decreased melanin (scars, stretch marks, vitiligo).
• Variations in color can be general or localized (scar tissue, freckling).
• Temperature variations occur due to environment or chronic perfusion issues.
• Hyperthermia: Elevated body temperature indicates a fever, potentially from an infection.
• Hypothermia: Generalized cool body temperature is associated with poor perfusion, such as during cardiac arrest or shock.
• Cyanosis: Bluish skin color in lighter skin tones indicates a lack of oxygen to the tissues.
• Ecchymosis: Bruising results from bleeding under the skin.
• Petechiae: Pinpoint red/purple spots of discoloration on the skin or mucous membranes, due to hemorrhages.
• Erythema: Skin appears flushed due to inflammation (intense red in lighter skin tones, purplish in darker skin tones).
• Jaundice: Yellowish skin color caused by increasing bilirubin levels.
• Pallor: Skin color is paler or lighter than usual.
• Hematoma: Localized collection of blood outside blood vessels.

Skin Integrity

• Expected findings: The skin should be dry and intact.
• Scars from trauma or procedures are expected.
• Good hygiene is considered an expected finding.
• Skin lesions: Variations in skin integrity, associated with trauma or disease.
• Vascular lesions: Result of blood leaking from vessels into the dermis.
• Purpura: Collection of petechiae and ecchymosis covering an area.

Primary Lesions

• Macule: Small area of pigmentation change.
• Patch: Large area of pigmentation change.
• Papule: Small raised area.
• Plaque: Larger raised disc-shaped area.
• Wheal: Irregular area of edema on the skin.
• Nodule: Small firm area arising from deeper in the dermis.
• Tumor: Larger firm area arising from deeper in the dermis.
• Vesicle: Small superficial area filled with serous fluid.
• Bulla: Larger superficial area filled with serous fluid.
• Pustule: Small superficial area filled with purulent fluid.
• Cyst: Encapsulated area filled with liquid or semi-solid fluid, arising from the dermis or subcutaneous layer.

Secondary Lesions

• Secondary lesions evolve from primary lesions over time, altering their characteristics.
• Potentially malignant lesions: Changes to the skin surface may indicate skin cancer.

Stages of Pressure Injuries

• Stage 1: Reddened, non-blanchable area with different texture and temperature than surrounding tissue.
• Stage 2: Partial skin loss of dermis; shiny or dry ulcer with pink wound bed; may present as intact or ruptured blister.
• Stage 3: Full-thickness skin loss with damage or necrosis to subcutaneous tissue; subcutaneous fat may be visible; may have dead tissue.
• Stage 4: Full-thickness skin loss resulting in exposed bone, tendon, or muscle; dead tissue may be present.

Moisture, Texture, Mobility, and Turgor

• Expected findings: Skin should rise easily when pinched and rapidly return to a flat position.
• Skin should be smooth and uniformly dry.
• Acne: Characterized by blackheads or whiteheads, pimples, oily skin, and scarring.
• Wrinkles are an expected finding.
• Scars are an expected finding.
• Tenting: Skin remains elevated after release, indicating significant weight loss or severe dehydration.
• Edema: Decreased skin mobility indicates edema, caused by excess fluid in interstitial spaces.
• Inspection and palpation assess swelling extent.
• Generalized edema indicates a central problem like heart or kidney failure, whereas localized edema is due to other causes such as infection or trauma.
• Skin will appear shiny and tight accompanied by an increased risk for pressure injury.
• Pitting (grades 1+ to 4+) signifies fluid retention levels
• Diaphoresis: Excessive perspiration is due to increased metabolic rate, fever, thyroid disorders, increased activity, shock, severe pain, anxiety, or heart failure.

Hair/Nails Assessment

• Hair: Evenly distributed and in good hygiene with adequate quantity.
• Nails: Symmetrical, smooth, and slightly curved or flat.
• The base edges of the nail at the cuticles should be smooth and rounded.
• Thickness should be uniform.
• The nail itself should be translucent and colored similar to the client's skin tone.
• Brown streaks may be present in those with darker skin tones due to increased pigmentation.
• Capillary refill: Should occur in less than 2 seconds.

Age-Related Skin Changes

• Sun exposure increases the risk of skin cancers.
• Less elasticity leads to skin tears.
• Stiffening collagen fibers and decreased fatty acids cause dryness.
• Uneven pigmentation can occur.
• Hair and nail growth slows.
• Nail discoloration and thickening can be observed.
• There is loss of subcutaneous tissue.
• Wrinkling is caused by UV exposure.

Ethnic Considerations: Skin Assessment

• Dark skin: Erythema or pallor are harder to detect (assess conjunctiva, palms, soles, tongue, and nail beds).
• Light skin: Erythema and pallor are more visible.
• Hyperpigmentation: Common in darker skin, often from acne or eczema.
• Cultural sensitivity: Be aware of the social sensitivity surrounding skin color and avoid stereotypes.

Ethnic Considerations: Hair Assessment

• African hair: Tightly coiled, prone to breakage. Traction alopecia can occur from hairstyles like braids or weaves.
• Asian hair: Generally straight and thick, but sensitive to chemical treatments.
• Hispanic/Latino hair: Varies widely, often smaller in diameter than Asian hair.
• Caucasians gray in mid-30s, Asians in late 30s, and Africans in mid-40s.
• Hair has cultural value, especially in African and Afro-textured hair communities.

Ethnic Considerations: Nail Assessment

• Linear pigmentation can be normal in darker-skinned individuals.
• Be aware of cultural practices affecting nail health, such as frequent nail polish use.

Health Promotion Strategies

• Bathing and hygiene: removes oil, sweat, dead cells, and bacteria, also promotes circulation.
• Skin care products should be carefully selected.
• Abrasions: Susceptible to infection, needing to be kept clean and dry.
• Excessive skin dryness: Cracking increases infection risk.
• Acne: Keep skin clean to lessen the risk of a secondary infection.
• Erythema: Carefully wash the area to eliminate bacteria.

Skin Protection from Sun Exposure

• Ultraviolet radiation from the sun is the most significant environmental risk for skin cancer.
• Apply broad-spectrum sunscreen (SPF 30 or higher) 15 minutes before going outdoors.
• Educate clients about skin cancer risks.
• Tell clients about increased melanoma risk with freckles and a large number/size of moles.

Wound Care and Diet

• A balanced diet containing protein promotes healing, such as lean meats, poultry, fish, eggs, nuts, and seeds,
• Eat foods high in antioxidants (berries, leafy greens, citrus fruits, tomatoes, and peppers).
• Eat foods with anti-inflammatory properties (ginger, turmeric, garlic, and oatmeal).

Pressure Wounds Risks

• Intrinsic factors are general health, nutrition status, age, history of previous ulcers.
• Extrinsic factors relate to pressure, friction, shear, mobility status.
• Spinal cord injury patients have high risk due to immobility and sensory loss.
• Turn patients every 2 hours.
• Use specialized mattresses and cushions.
• Keep the skin clean and dry, use moisturizers, avoid harsh soaps and talc powder
• Ensure adequate nutrition and hydration.
• Document the visual description of the wound (type, size, location, stage, tissue, type, and color).
• Conduct regular pressure injury risk assessments.
• Include relevant patient behavior and compliance with treatment.
• Use a consistent system for documentation.
• Accurately code pressure ulcers by stage, and report each ulcer separately.