MONITORING BEDSORE

DR. SAFAA HUSSEIN ALILECTURER OF GERIATRIC

MEDICINEAIN SHAMS UNIVERSITY

CAIRO – EGYPTCONSULTANT OF GERIATRIC

MEDICINE

WHAT IS THE BRADEN SCALE?

• The vast majority of nurses use special scoring system to evaluate a patient’s risk of developing a pressure ulcer. The most preferred tool is the Braden Scale for Predicting Pressure Sore Risk. It consists of six categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score can range from 6 to 23 with a lower score indicating a higher risk. The level of risk indicates the intervention strategies that should be used. 

AT RISK (BRADEN SCORE 15 – 18) PREVENTIVE INTERVENTIONS:

• Turn the patient on a regular schedule.• Help the patient be as active as possible.• Protect the patient’s heels.• Use pressure-redistribution surfaces.• Manage moisture, nutrition, friction, and shear.• Advance to a higher level of risk if other major

risk factors are present.

MODERATE RISK (BRADEN SCORE 13 – 14) PREVENTIVE INTERVENTIONS:

• Use same protocol as for ‘at risk’ patients.• Position patient

at 30° lateral incline using foam wedges.

HIGH RISK (BRADEN SCORE 10 – 12) PREVENTIVE INTERVENTIONS:

• Use same protocol as for ‘moderate risk’ patients.• In addition to turning the patient on a regular

schedule, make small shifts in their position.

VERY HIGH RISK (BRADEN SCORE = 9) PREVENTIVE INTERVENTIONS:

• Use same protocol as for ‘high risk’ patients.• Add a pressure-

redistribution surface for patients with severe pain or with additional risk factors.

MESURE TUNNELING

MAP

• (Monitor Alert Protect) system• MAP

• MAP consists of a pressure-sensing mat that sits on top of the bed, wired to a monitor that provides color-coded visual feedback for repositioning patients so that pressure points on the body are consistently rotated. The system can be customized for each facility and even for each patient.