Understanding the Braden Scale and the Friction/Shear Subscale
The Braden Scale is a comprehensive, evidence-based assessment tool used to predict a patient's risk of developing pressure ulcers, also known as bedsores or pressure injuries. Developed in 1987, it assesses six distinct risk factors: sensory perception, moisture, activity, mobility, nutrition, and, crucially, friction and shear. Each of these subscales is evaluated to provide a total score, which informs a patient's overall risk level.
While most subscales are rated on a 1-4 scale, the friction and shear component is unique, using a 1-3 scale. This distinction is important because friction and shear represent different types of mechanical damage to the skin and underlying tissues. Friction is the force created when the skin rubs against a surface, like bedsheets, causing superficial abrasions. Shear, however, is a more serious issue involving the skin and underlying soft tissue layers being pulled in opposite directions. This can damage blood vessels and is often caused by a patient sliding down in a bed or chair. The proper interpretation of this score is a cornerstone of effective preventative nursing care.
Detailed Breakdown of the Friction and Shear Scores
The three-point scale for friction and shear is straightforward, with each point corresponding to a specific level of risk:
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Score of 1: Problem. This rating is assigned to patients who are completely dependent on others for movement and positioning and frequently slide down in a bed or chair. These individuals are at a high risk for tissue damage from friction against sheets and the shearing force caused by sliding. This often includes patients who are bedbound, have spinal cord injuries, or are sedated or intubated. The inability to assist with their own repositioning makes them highly vulnerable.
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Score of 2: Potential Problem. A patient with this score requires at least minimal assistance to move. While they may not be constantly sliding, their skin can still rub against surfaces during repositioning or transfers. An individual who can occasionally lift themselves but struggles with frequent repositioning would fall into this category. This score signals a moderate risk and the need for careful monitoring and some preventative interventions.
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Score of 3: No Apparent Problem. This highest possible score is given to patients who can move in bed and a chair independently, and who have sufficient muscle strength to lift themselves completely during a move, avoiding friction and shear. These individuals can maintain their position without sliding. While this indicates low risk from friction and shear, it does not preclude them from having other risk factors on the overall Braden Scale.
How to Assess for Friction and Shear
To accurately assess the friction and shear risk, a healthcare provider should:
- Observe movement: Watch how the patient moves or is moved. Do they slide? Do they struggle to reposition themselves?
- Evaluate assistance needed: Note the level of assistance required for transfers and position changes. Is it minimal, moderate, or complete dependence?
- Inspect skin: Look for signs of skin damage, such as redness or abrasions, particularly over bony prominences.
- Consider the environment: Assess the patient's bedding and chair surfaces for potential friction sources. Are the sheets wrinkled or damp? Does the chair surface cause friction?
Preventative Interventions Based on Friction and Shear Score
The assessment is only the first step. Interventions must follow the scoring to be effective:
| Score | Risk Level | Intervention Strategies |
|---|---|---|
| 1 | High Risk | Aggressive Prevention: Use trapeze bars to aid patient movement, employ lift sheets or friction-reducing devices for all transfers, use pressure-reducing surfaces like specialized mattresses, and ensure frequent repositioning. |
| 2 | Moderate Risk | Moderate Prevention: Implement heel/elbow protectors, use a turning schedule, and consider specialty mattresses. Patient education on moving safely and using assistance is key. |
| 3 | Low Risk | Standard Care: Encourage independent movement. Ensure bed linens are clean, dry, and wrinkle-free. Monitor for any changes in condition that could increase risk. |
It is important to remember that a single subscale score does not determine a patient's total risk. The final Braden Score is a sum of all six subscales, providing a holistic view of the patient's susceptibility to pressure ulcers. For instance, a patient with a high score for mobility (low risk) but a low score for moisture (high risk) still needs a carefully planned intervention strategy.
Best Practices in Patient Repositioning
To minimize friction and shear, nursing staff and caregivers should adhere to best practices for repositioning patients. These include:
- Lift, don't drag: Use devices like lift sheets or trapeze bars to lift the patient and move them, rather than dragging them across a surface. This prevents the shearing force that can damage capillaries.
- Utilize a repositioning schedule: Based on the overall Braden score, establish a regular schedule for repositioning that ensures no single pressure point is stressed for too long.
- Educate the patient: If the patient is able to assist, teach them proper techniques for shifting their weight and using supportive devices.
- Ensure proper transfer techniques: When moving a patient from a bed to a chair, or vice versa, use a safe transfer technique that minimizes dragging and sliding. Utilizing a gait belt or a lift can be helpful.
The Role of Assistive Devices and Education
Numerous assistive devices are available to help prevent friction and shear-related injuries. Low-friction transfer sheets and specialized booties or elbow pads can provide a barrier between the patient's skin and external surfaces. For patients at higher risk, advanced support surfaces such as air-fluidized or low-air-loss mattresses can redistribute pressure and minimize forces that cause skin damage. Furthermore, continuous education for healthcare professionals on proper lifting and repositioning techniques is crucial for maintaining patient safety and preventing injuries. For more information on wound care education, resources are available from institutions like the Wound Care Education Institute, which provides professional training and certifications(https://blog.wcei.net/braden-scale-score-for-predicting-pressure-injury-risk). Regular training ensures that all staff understand the nuances of the Braden Scale and how to apply preventative measures effectively.
Conclusion
In conclusion, the Braden Scale's friction and shear score, though based on a smaller scale of 1 to 3, is a critical component for identifying a patient's risk of pressure injuries. By accurately assessing a patient's ability to move independently and their potential for sliding, healthcare providers can implement targeted, preventative interventions. This proactive approach is essential for protecting the skin integrity of vulnerable individuals, particularly older adults or those with limited mobility. Understanding the distinctions between friction and shear and how to interpret the scores empowers caregivers to provide a higher standard of care, ultimately improving patient outcomes.
