Question

1. What are the components of the Braden Scale, and how are the components scored?

2. What are the characteristics of ulcers in each stage of pressure ulcers?

Answer 1

1.

Briefly put, the Braden Scale is an evidenced-based tool, developed by Nancy Braden and Barbara Bergstrom, that predicts the risk for developing a hospital or facility acquired pressure ulcer/injury. The Braden Scale uses a scores from less than or equal to 9 to as high as 23. The lower the number, the higher the risk for developing an acquired ulcer/injury.

19-23 = no risk
15-18 = mild risk
13-14 = moderate risk
less than 9 = severe risk

There are six categories within the Braden Scale: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

2.

The first stage is the mildest. It discolors the upper layer of your skin, commonly to a reddish color. In this stage, the wound has not yet opened, but the extent of the condition is deeper than just the top of the skin. The affected area may be sore to touch but has no surface breaks or tears. You may also experience mild burning or itching.

You may notice that the area is red and your skin does not turn pale when pressed firmly. This means there is an interruption in blood flow and that an ulcer is forming. The texture and temperature of this developing sore will likely also be different from the surrounding normal tissues.

Treatment

The first step to treating an ulcer in this stage is to remove pressure from the area. Any added or excess pressure can cause the ulcer to break through the skin surface. If you are lying down, adjust your position or use pillows and blankets as extra padding.

It’s also important to keep the affected area clean and dry to reduce tissue damage. Stay well hydrated, and add foods high in calcium, protein, and iron to your diet. These foods help with skin health.

If treated early, developing ulcers in stage one can heal in about three days.

Stage 2

In the second stage, you’ll likely experience some pain from the ulcer. The sore area of your skin has broken through the top layer and some of the layer below. The break typically creates a shallow, open wound and you may or may not notice any drainage from the site.

A stage 2 ulcer may appear as a serum-filled (clear to yellowish fluid) blister that may or may not have burst. The surrounding areas of the skin may be swollen, sore, or red. This indicates some tissue death or damage.

Treatment

Similar to treating stage 1 pressure ulcers, you should treat stage 2 sores by removing pressure from the wound. You must seek medical attention for proper treatment.

Your doctor will advise you to keep this area dry and clean. Clean the sore with water or a mild, sterile saltwater solution to dry out the wound. You may experience some pain or stinging.

Once you’ve cleaned the ulcer, discuss how to properly bandage it with your doctor. It’s also important to monitor the wound for any signs of infection including:

• worsening pain
• pus
• red skin
• fever

Healing from this stage can last anywhere from three days to three weeks.

Stage 3

Sores that have progressed to the third stage have broken completely through the top two layers of the skin and into the fatty tissue below. An ulcer in this stage may resemble a crater. It may also smell bad.

In this stage, it’s important to look for signs of infection including:

• foul odor
• pus
• redness
• discolored drainage

Treatment

You must seek immediate medical treatment if you have a stage 3 pressure ulcer. These sores need special attention. Your doctor may prescribe antibiotic therapy and remove any dead tissue to promote healing and to prevent or treat infection.

If you are immobilized, your doctor may recommend a special mattress or bed to relieve pressure from the affected areas. Ulcers in this stage usually need at least one to four months to heal.

Stage 4

Stage 4 ulcers are the most serious. These sores extend below the subcutaneous fat into your deep tissues like muscle, tendons, and ligaments. In more severe cases, they can extend as far down as the cartilage or bone. There is a high risk of infection at this stage.

These sores can be extremely painful. You can expect to see drainage, dead skin tissue, muscles, and sometimes bone. Your skin may turn black, exhibit common signs of infection, and you may notice a dark, hard substance known as eschar (hardened dead wound tissue) in the sore.

Treatment

People with stage 4 pressure ulcers need to be taken to the hospital immediately. Your doctor will likely recommend surgery. Recovery for this ulcer can take anywhere from three months to two years to completely heal.

Additional types

In addition to the four main stages of pressure ulcer formation, there are two other categories: suspected deep tissue injury and unstageable pressure ulcers.

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Ulcers that form from suspected deep tissue injury can be difficult to diagnose. On the surface, it may resemble a stage 1 or 2 sore. Underneath the discolored surface, this ulcer could be as deep as a stage 3 or stage 4 wound. This pressure ulcer may also form as a blood blister, or be covered with eschar.

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Unstageable pressure ulcers are also hard to diagnose because the bottom of the sore is covered by slough or eschar. Your doctor can only determine how deep the wound is after clearing it out.

The ulcer may be yellow, green, brown, or black from slough or eschar. If there is extensive tissue damage, it will need to be surgically removed. However, in certain areas of the body, if the covering is dry and stable, it shouldn’t be touched. This dry eschar is the body’s natural layer of protection.