Braden Scale

Overview

Pressure injury risk assessment tool scoring sensory perception, moisture, activity, mobility, nutrition, and friction/shear (6-23, lower=higher risk). Braden Scale components and scoring tested on CNA exam.

Resident care connections: Right to communicate freely with phone access, mail unopened, visitors at reasonable hours. Right to be treated with dignity and respect at all times.

Step-by-Step Procedure

Step-by-step procedure for oral care (applicable to braden scale):

1. Position at 45 degrees or side-lying if unconscious
2. Brush teeth/dentures with soft brush
3. Swab oral cavity for unconscious patients
4. Apply lip moisturizer

Safety note: Unconscious: position to side, suction available. Remove dentures nightly, soak in denture solution.

Assessment Techniques

Assessment observations for braden scale that must be reported to the nurse:

• Report to nurse: elevated temperature, blood pressure outside baseline, new pain, skin breakdown
• I and O (intake and output): measure and record all fluids consumed and excreted in mL
• Behavioral changes: new confusion, agitation, refusing meals, sleep pattern changes
• Fall risk factors: history of falls, medications (sedatives, diuretics), mobility impairment, cognitive decline

Clinical Significance

For nursing assistants, braden scale connects to fundamental resident care principles. Residents always retain the right to:

• Right to be free from restraints (physical and chemical) except for documented medical necessity
• Right to refuse treatment including medications, procedures, and activities
• Right to participate in care planning and be informed about condition and treatment changes

Workplace Applications

Applying braden scale in daily practice as a nursing assistant:

• Right to be free from restraints (physical and chemical) except for documented medical necessity
• Right to refuse treatment including medications, procedures, and activities
• Right to manage own financial affairs or choose a representative
• Report behavioral changes to the nurse: withdrawal, aggression, crying, confusion
• For hearing-impaired: face the resident, speak clearly (not louder), reduce background noise
• Therapeutic silence: allow time for the resident to process and respond