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1 This is a Sample version of the The Braden Pressure Sore Scale - Kit (BPSS-kit) The full version of BPSS-kit comes without sample watermark.. The full complete version includes - BPSS Overview information - BPSS Scoring/ Administration instructions - BPSS Complete questionnaire - BPSS Clinical Validity - BPSS Training Video - BPSS protocol poster - PS Skin Data collect Assessment Tool - PS Schedules Timer Buy full version here - for $ Clicking the above buy now button will take you to the PayPal payment service website in which you can pay via credit card or your optional PayPal account. Once you have paid for your item you will receive a direct link to download your full complete e-book instantly. You will also receive an with a link to download your e-book. Each purchased product you order is available to download for 24 hours from time of purchase. Should you have any problems or enquiries please contact - info@agedcaretests.com

2 Braden Scale for Pressure Sore Risk in a Nursing Home Population Barbara J. Braden and Nancy Bergstrom The predictive validity of the Braden Scale and the timing of assessment for optimal prediction of pressure sore development (PS) were studied in a nursing home population. Subjects (N = 102) over age 19, free of PS and admitted within the previous 72 hr, were randomly selected from consecutive admissions to a skilled nursing facility. Subjects were assessed for risk and skin condition every 48 to 72 hr for 4 weeks. Twenty-eight subjects (27.5%) developed a PS. A cut score of 18 used at the observation prior to the first recorded PS maximized prediction, producing a sensitivity of 79%. a specificity of 7470, a 54% predictive value of a positive test, 90% predictive value of a negative test, and 75% correct classification rate John Wiley & Sons, Inc. Pressure sores (PS) represent one of the most serious complications of an increasingly fragile elderly population (National Pressure Ulcer Advisory Panel [NPUAP], 1989). Prevention of this complication is dependent upon the clinician s ability to estimate the degree to which a patient is at risk and to intervene appropriately. Screening tests facilitate prevention by formalizing esti-.mates of risk and differentiating persons who are at risk for developing PS from among the many who are not. Rating scales are the most common screening tools used to identify patients at risk for PS. Several of these risk prediction scales have been reported (Bergstrom, Braden, Laguzza, & Holman, 1987; Gosnell, 1973; Norton, McLaren, & Exton-Smith, 1962), all using summative rating scales and specifying cut scores indicative of risk. The Norton Scale, for example, consists of five parameters: physical condition, mental state, activity, mobility, and incontinence. Each is rated from 1 to 4 with one- or two-word descriptors for each rating. Scores range from 5 to 20 with a score of 14 indicating onset of risk and a score of 12 or below indicating a high risk. A second tool (Gosnell, 1973) consists of five parameters or subscales: mental status, continence, mobility, activity, and nutrition. Two- or three-sentence descriptive statements are provided for each rating. Possible scores range from 5 to 20, and a score < 16 is indicative of risk. Scoring was later revised (Gosnell, 1989) so that high scores would denote greater risk. A third instrument, the Braden Scale (Bergstrom, Braden, Laguzza, & Holman, 1987; Bergstrom, Demuth, & Braden, 1987; Braden & Bergstrom, 1989) is composed of six subscales reflecting sensory perception, skin moisture, ac- Barbara J. Braden, PhD, RN, is a professor, School of Nursing, Creighton University, and Nancy Bergstrom, PhD, RN, is a professor, College of Nursing, University of Nebraska Medical Center. This study was runded by the National Center for Nursing Research, NIH, Grant No. R01 NR The is contributions the endof Nell ofarmstrong, the SAMPLE PhD, RN, Kashinath BPSS-kit D. Patil, PhD, clinical Elizabeth Ruby in data analysis, goto and Diane page McGee, 1BSN, torn, purchase and Mary Ann Dorsey, complete BSN, RN, in version. data collection are acknowledged. This article was received on January 28, 1992, revised, and accepted for publication on April 15, Requests for reprints can be addressed to Dr. Barbara Braden, School of Nursing, Creighton University, 2500 California Plaza, Omaha, NE This Please validity John Wiley & Sons, Inc. CCC /94/

3 Predicting Pressure Ulcer Risk WHY: Pressure ulcers (PUs) occur frequently in hospitalized, community-dwelling and nursing home older adults, and are serious problems that can lead to sepsis or death. Prevalence rates for PUs are 11.9% in acute care, 29.3% in long term acute care, 11.8% in long term care, and 19.0% in rehabilitation. A key to prevention is early detection of a patient s risk factors which includes using a valid and reliable PU risk assessment tool and timely implementation of prevention interventions. SCORING INSTRUCTIONS: The Braden Scale for Predicting Pressure Sore Risk, is among the most widely used tools for predicting the development of PUs. Assessing risk in six areas (sensory perception, skin moisture, activity, mobility, nutrition and friction/shear), T he Braden Scale assigns an item score ranging from - one (highly impaired) to three/four (no impairment). When completing the Braden Scale choose one item the most accurately discribes the wound for each 6 areas. VALIDITY AND RELIABILITY: The ability of the Braden Scale to predict the development of PUs (predictive validity) has been tested extensively. Inter-rater reliability between.83 and.99 is reported. The tool has been shown to be equally reliable with Black and White patients. Sensitivity ranges from % and specificity 64-90% depending on the cut-off score used for predicting PU risk. A cut-off score of 18 or low subscale scores should be used for identifying at risk for patients. STRENGTHS AND LIMITATIONS: When utilized correctly and consistently, the Braden Scale helps identify the associated risk for PU so that appropriate preventive interventions can be implemented. Although the Braden Scale has been used primarily with White older adults, research addressing Braden Scale efficacy in Black and Latino populations suggests that a cut-off score of 18 or less prevents under-prediction of PU risk in these populations. This is the end of the SAMPLE BPSS-kit scoring instructions.

4 Protocols by Level of Risk AT RISK (15-18)* FREQUENT TURNING MAXIMAL REMOBILIZATION PROTECT HEELS MANAGE MOISTURE, NUTRITION AND FRICTION AND SHEAR PRESSURE-REDUCTION SUPPORT SURFACE IF BED- OR CHAIR-BOUND * If other major risk factors are present (advanced age, fever, poor dietary intake of protein, diastolic pressure below 60, hemodynamic instability) advance to next level of risk MODERATE RISK (13-14)* TURNING SCHEDULE USE FOAM WEDGES FOR 30! LATERAL POSITIONING PRESSURE-REDUCTION SUPPORT SURFACE MAXIMAL REMOBILIZATION PROTECT HEELS MANAGE MOISTURE, NUTRITION AND FRICTION AND SHEAR * If other major risk factors present, advance to next level of risk MANAGE MOISTURE USE COMMERCIAL MOISTURE BARRIER USE ABSORBANT PADS OR DIAPERS THAT WICK & HOLD MOISTURE ADDRESS CAUSE IF POSIBLE OFFER BEDPAN/URINAL AND GLASS OF WATER IN CONJUNCTION WITH TURNING SCHEDULES MANAGE NUTRITION INCREASE PROTEIN INTAKE INCREASE CALORIE INTAKE TO SPARE PROTEINS. SUPPLEMENT WITH MULTI-VITAMIN (SHOULD HAVE VIT A, C & E) ACT QUICKLY TO ALLEVIATE DEFICITS CONSULT DIETITIAN This is the end of the SAMPLE BPSS-kit protocol poster.

5 BRADEN SCALE For Predicting Pressure Sore Risk in Home Care Patient's Name: Evaluator's Name: Date of Assessment: SENSORY PERCEPTION ability to respond meaningfully to pressurerelated discomfort MOISTURE degree to which skin is exposed to moisture 1. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation. OR Limited ability to feel pain over most of body. 1. Constantly Moist Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. 2. Very Limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness. OR Has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body. 2. Often Moist Skin is often, but not always moist. Linen must be changed as often as 3 times in 24 hours. 3. Slightly Limited Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR Has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. 3. Occasionally Moist Skin is occasionally moist, requiring an extra linen change approximately once a day. 4. No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. 4. Rarely Moist Skin is usually dry; Linen only requires changing at routine intervals. ACTIVITY degree of physical activity 1. Bedfast Confined to bed. 2. Chairfast Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. 3. Walks Occasionally Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of day in bed or chair. 4. Walks Frequently Walks outside bedroom twice a day and inside room at least once every two hours during waking hours. This is the end of the SAMPLE BPSS-kit questionnaire.

6 PRESSURE SORE DATA COLLECTION SKIN ASSESSMENT TOOL Name: DATE OF OBSERVATION: Skin Temperature: Tissue consistency: Sensation: (MM/DD/YEAR) ASSESSMENT SITE* SKIN CONDITION 1) Back of head 2) Right ear 3) Left ear 4) Right scapula 5) Left scapula 6) Right elbow 7) Left elbow 8) Vertebrae (upper-mid) 9) Sacrum 10) Coccyx 11) Right iliac crest 12) Left iliac crest Stage 1 Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage 2 Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

7 SKIN ASSESSMENT TOOL (page 2) Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk) Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. *Bruising indicates suspected deep tissue injury Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable. This is the end of the SAMPLE BPSS-kit Skin Data collect tool.

8 Turning Schedules Turning schedules may be used to organize care on nursing units with large numbers of patients who are at risk for pressure sores. Patients on a team or unit can be assigned to one of three schedules in a balanced manner, e.g. if six patients are at risk, 2 would be assigned to each of the three schedules. These schedules may have to be adjusted to each day, depending on other components of the patient s schedule. Direction of Turn Schedule 1 Schedule 2 Schedule 3 Back (breakfast/bath) 7:00-9:00 a.m. 7:30-9:30 a.m. 8:00-10:00 a.m. Right side 9:00-11:00 9:30-11:30 10:00-noon Back (lunch) 11:00-1:00 p.m. 11:30-1:30 p.m. 12:00-2:00 p.m. Left side 1:00-3:00 1:30-3:30 2:00-4:00 This is the end of the SAMPLE BPSS-kit Schedules Timer.