Using a BradenRisk Tool to reduce the risk of pressure damage.

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Sensory Perception / Patients are not responsive to any touch voice or pain consider :-
,locked in syndrome ,brain injury ,tetraplegic ,End of Life end stage dementia ,Any long term condition which is very advanced and nearing the end stage . / Dementia patients ,
Patients with mental health issues such as severe depression
Paraplegic
Gross oedema
Multiple Sclerosis,Moto neurone Disease CerebralVascular accident. / Dementia patients, patients with brain injury.
Diabetic patients with lower limb neuropathy,
Patients with lymphoedema , chronic oedema
Hypoxia. / Patients are able to voice any issues with pain and sensation and have full sensory systemsworking.
Moisture / Patients who sweat a lot ,
Patients who have unresolved’ weepy’ legs,
Patients who have un managed continenceissues due to concordance or mental capacity.
Care issues. / Patients have need of clothing, bedding orpads (this could also be wound dressings,-to be changed at least 3 times a day (this may not happen but they need it.) / At least once a day there is an issue with moisture that needs to be removed from the patient’s skin
. At least once a day, dressings, pads, urinary aids leaking. / Patient is not unduly sweaty.
Does not have a continence problem.
Wound exudate is contained due to proper treatment and appropriate absorbent dressings.
Activity / Patient spends at least 22hours a day in bed. They are still bedbound if they sit out to use the commode and have their bed made. / Means they need assistance to get out of the chair. Can only stand and transfer.
Long sits 3 hrs or more. / Can only walk within the room /to toilet.
Not more than 3x a day short walk.
Needs prompting to move. / Patient is independent and motivated to walk.
Walking is not restricted to any areas.
Mobility / Cannot move, position is adjusted and assisted by another. End Of Life patients. end stage chronic conditions:- coma general frailty,Patients who do not move due to other health issues such as pain, breathing difficulties, partial or full paralysis ,obesity. / May only be able to move certain parts of their body like head arm /hand flex feet unable to make meaningful changes consider patients that have unmanaged pain chronic fatigue, obesityremember assessment should be over a 24hr period. / Can make slight changes e.g.-
patient is able to move heels if painful
Patient can tilt their body from side to side, but unable to roll over.
They are unable to fully move off key pressure points. E.g. – patients with breathing issues, contractures, postural deformities, multiple pressure damage. / Patients who can and do move position when uncomfortable.
Can maintain their own position,
Nutrition / Patient has not eaten for at least 5 days.
Eats only third of all meals. Has poor fluid intake
Has serum albumin levels (blood)under 35g/l
This may be due to:-
End Of Life
Acute illness /surgery
Mental illness -depression ,mania anorexia
Dementia
Unsafe swallow, CVA, MND,
Malabsorption issues.
Must score of 2 and above. / Eats only half as what is given to eat and drink.
Quality of diet is poor and out of balance. Patient eats sporadically.
L ow protein and nutrients in diet. history of weight loss MUST score of 1 and above
Large loss of wound exudate. / Eats over half of most meals.
Eats a total of 4 servings of protein a day (but do they? (meat, dairy ,nuts,beans (check portion size)
Is tube fed and is increasing or maintaining weight? / Normal diet MUST of 0
Eats 4 or more portions of protein a day.
May eat in-between meals
Maintains a stable weight.
  • Shear and friction
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  • Has poor core stability.
  • Needs frequent repositioning by another.
  • Has postural deformities curvature of the spine, rounding of shoulders, pelvic misalignment.
  • Incorrect size and type of equipment.
  • Spasticity, contractures or agitation leads to almost constant friction.
/ Patient is feeble but can only maintain position for short periods of time.
Tiredness and fatigue lead to increased risk of shear and friction.
Patients has opportunities to rest and recover ( laying on the bed in between sitting)
Poor sitting to standing, dragging bottom, unable to move positioncleanly.
Cushions/ pillows in chairs havechanged patientposition. / No problems can maintain and move their position when required

Braden risk tool/decision tree V2