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The Braden Scale
The Braden Scale is a summated rating scale
made up of six subscales scored from 1-3 or 4, for total scores
that range from 6-23. The subscales measure functional capabilities
of the patient that contribute to either higher intensity and duration
of pressure or lower tissue tolerance for pressure. A lower Braden
Scale Score indicates lower levels of functioning and, therefore,
higher levers of risk for pressure ulcer development.
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Basic Protocols
Basic protocols based on Braden Scale scores are provided.
The intensity of the preventive interventions being recommended
increase as the level of risk rises. These protocols are easily
understood by staff and, if they are consistently followed, have
been found to reduce the incidence of pressure ulcers.
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Skin Assessment Tool
The Skin Assessment Tool© is a useful instrument
for assessment of the skin surface for lesions. It directs the caregiver
to systematically evaluate 29 of the most common sites of pressure
ulcer occurrence. A head-to-toe assessment of skin condition should
be conducted daily for at-risk patients.
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