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Braden Score: Case Studies
1&2
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Case study # 1
• 75-year-old male with Non-Hodgkins
lymphoma, Alert and oriented
• Height 5’9”, Weight 160 lbs.
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Braden Score
• Moisture 3
4
Braden Score
• Activity 2
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Braden Score
Nutrition 2
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Braden Score
• Friction/Shear
2
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Braden Score
Case Study # 2
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Case study #2
• Mrs. West is a 79- year old widowed female
admitted to the nursing home after a right hip
fracture.
• She lives alone. Her daughter lives close by and
visits frequently.
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Case study #2
• Past Medical History includes:
▫
▫
▫
▫
Hypertension
DM Type II insulin dependent
Anxiety Disorder
Osteoarthritis
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Case study #2
• During hospitalization:
▫ Her anti-hypertension medications were restarted
and adjusted.
▫ After surgical hip pinning, PT and OT were
ordered on the first day post-op for exercises,
ROM, transfer, and ADL training.
 She refused therapy due “I just don’t want to get out
of bed yet”.
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Case study #2
Post-Op day 1
• PT reports that when she allows them to get her
out of bed she requires assistance of two for safe
transfers. OOB usually only once a day. Staff
often find her slumped in the chair and have to
put her back to bed.
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Case study #2
• She reports pain in right hip 5/10 and 2/10 in left
knee from arthritis.
• She is refusing any pain meds , “its too much
trouble for those little girls, they are busy.”
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Case study #2
• She only consumes 50% of her food at each
meal. She able to feed herself.
• Her height and weight are:
▫ 63 inches (5 foot ,3 inches)
▫ 105 pounds
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Case study #2
• She is continent of urine but has occasionally
has been found to be wet when staff have turned
her.
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Case study #2
• Preferred position is supine with head of bed
elevated with pillow under right leg.
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Case study #2
Post-Op day
• Night shift nurse noted that there is a 1.0 CM X
2.0 cm non-blanchable reddened area on coccyx.
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Case study #2
Discharge Day
• She is discharged to NH for PT/OT
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Braden Score
What is the total score?
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Case study # 1
• Spends most of the day in bed. Makes
occasional slight changes in body or extremity
position but unable to make frequent or
significant changes independently.
• Occasionally slides down to foot of bed,
requiring some assistance to move back to the
top.
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Case Study: # 2
• Able to walk a short distance to the chair with
assistance
• Hgb = 8.5, Serum Albumin 3.1
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Case Study: # 2
• Incontinent of stool
• Continent of urine – uses urinal as needed
• Skin occasionally moist from incontinence
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Case Study # 2
• Admitting Orders:
▫ Tube feeding formula 400cc q 4 hours per PEG
▫ Dietician consult for tube feeding
recommendations
▫ Up in chair daily
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Case study # 2
Using the Braden Scale, what is Mr. W.G.’s sensory
perception score?
A.
B.
C.
D.
1 (Completely Limited)
2 (Very Limited)
3 (Slightly Limited)
4 (No Impairment)
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Sensory Perception
• 4 (No Impairment)
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Case study # 2
Using the Braden Scale, what is Mr. W.G.’s
moisture score?
A.
B.
C.
D.
1 (Constantly Moist)
2 (Very Moist)
3 (Occasionally Moist)
4 (Rarely Moist)
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Moisture
• 3 (Occasionally Moist)
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Case study # 2
Using the Braden Scale, what is Mr. W.G.’s activity
score?
A.
B.
C.
D.
1 (Bedfast)
2 (Chairfast)
3 (Walks Occasionally)
4 (Walks Frequently)
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Activity
• 2 (Chair fast)
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Using the Braden Scale, what is Mr. W.G.’s
mobility score?
A.
B.
C.
D.
1 (Completely Immobile)
2 (Very Limited)
3 (Slightly Limited)
4 (No Limitations)
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Mobility score
• 2 (Very Limited)
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Using the Braden Scale, what is Mr. W.G.’s
nutrition score?
A.
B.
C.
D.
1 (Very Poor)
2 (Probably Inadequate)
3 (Adequate)
4 (Excellent)
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Nutrition
• 3 (Adequate)
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Braden Score
• Sensory 4
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Case study # 1
Using the Braden Scale, what is Mr. W.G.’s friction
and shear score?
A. 1 (Problem)
B. 2 (Potential Problem)
C. 3 (No Apparent Problem)
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Friction and Shear
• 2 (Potential Problem)
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Case study # 1
Based on Mr. W.G.’s total Braden Scale Score,
indicate his level of risk for developing a
pressure ulcer.
A.
B.
C.
D.
E.
9 or less = Very high risk
10-12 = High risk
13-14 = Moderate risk
15-18 = Mild risk
19-23 = Generally not at risk
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Based on Mr. W.G.’s total Braden Scale Score,
indicate his level of risk for developing a
pressure ulcer.
A.
B.
C.
D.
E.
9 or less = Very high risk
10-12 = High risk
13-14 = Moderate risk
15-18 = Mild risk
19-23 = Generally not at risk