The following article is one that I used for the hospital nursing units newsletters. A more in depth explanation enabled the staff to have a better understanding of the Braden Scale which we use to determine the "At Risk" score. Please feel free to use this information. My staff felt it really helped them. Kathryn Dere

The focus of this article is to assist your understanding of what the "RISK SCORE" is all about. I thought an explanation of what RISK SCORE means, the purpose of the score, and why it is so important to complete the score on the flow sheet, would be beneficial. It also highlights the patient/s that needs following and close inspection during weekly skin rounds.

The RISK SCORE is derived from the Braden Scale that helps the caregiver identify the patient at high risk for breakdown over the bony prominence. The scale is composed of 6 subscales that reflect degrees of sensory perception, skin moisture, physical activity, nutritional intake, friction and shear, and the ability to change or control body position.

Sensory perception is not related to the neurologic function, but whether the patient is able to inform the caregiver that her/his buttocks or heel hurts. Sedation, paralytic agents, decreased LOC; all play a major part in this section.

Is the patient incontinent? Does he have a large or small draining wound? Is the skin overloaded with fluid and the skin blistered and weepy as a result? These are things I consider when assessing the skin for moisture.

Most patients, with hip surgery, have a wedge between their knees to prevent the hip from dislocating. This also restricts movement and the ability to shift from the area of discomfort.

There are several factors to look at when assessing nutritional status. Most patients are receiving nutrition via eating, tube feedings, or total parental nutrition via IV. I consider that most patients in the hospital are at maximum metabolic rates, using everything we give them and then some. What about the oxygenation to those microcells? Are any vasoactive agents being given? Is the patient septic or have a infection? Is circulation being compromised? Then it follows that nutrition and oxygen to the cells are compromised. This will give the patient a lower score on your assessment.

Mobility plays a big role in whether your patient develops pressure breakdown. Your patients may be heavy and unable to change position or shift weight, until the caregiver pulls them up and repositions them. What do you think happens to the gluteal fold, coccyx and sacral area when the patient is slightly moist, being pulled across sheets, or sliding down the bed? The skin sticks to the sheet, the skeleton sinks into the bed, and the capillaries below the surface are stretched and torn. This is SHEAR.

The RISK SCORE helps to identify the patient at high risk for breakdown quickly. Our Policy states RISK SCORE to be completed at admission, change in status, on transfer from another unit I.E.: ER, floor, and daily. Specialty Beds are available to help prevent and/or reduce further breakdown. The lower the score, the greater need for pressure reduction. If the score is 12 or less, a consult should be placed to the Wound Management Team to assist with the prevention plan of care.

The Wound Management Team oversees the specialty beds. The team should be consulted for placement needs in order to select the correct support surface for that patient. In this way, the beds are utilized in the optimal way with best outcomes for the patient.

One other thing, when a specialty bed is ordered in the computer, the Wound Management Team receives an automatic consult for the bed only. If the patient is compromised enough to need a bed, protocol states that the Wound management Team needs to be consulted separately when the RISK SCORE IS 12 or below. As team members, the Wound Management Team is here to assist in any way needed. Sometimes, our bag has tricks that could really make a difference...

Kathryn Dere, RN, MSN, CWOCN