From the Guidelines
A patient with a Braden score of 20 generally does not require intensive pressure injury prevention measures as this score indicates low risk for pressure ulcer development. Standard preventive care is sufficient, including regular skin assessment during routine care to monitor for early signs of skin breakdown, as suggested by the American College of Physicians guideline 1. Encourage normal mobility and activity as tolerated by the patient, as this score suggests they likely have good mobility, activity level, sensory perception, and skin moisture management. Ensure the patient maintains adequate nutrition and hydration to support overall skin health.
Key Preventive Measures
- Standard hospital mattresses are typically appropriate, without the need for specialized pressure-redistributing surfaces, according to the evidence from 1 and 1.
- Implement routine position changes every 2-4 hours if the patient has any mobility limitations.
- The Braden scale assesses six risk factors (sensory perception, moisture, activity, mobility, nutrition, and friction/shear), with scores ranging from 6-23; a score of 20 indicates the patient has minimal impairment in these areas and thus a low risk of developing pressure injuries. However, continue to reassess the Braden score regularly, as the patient's condition may change over time, as recommended by the clinical practice guideline from the American College of Physicians 1.
From the Research
Preventive Measures for a Patient with a Braden Score of 20
The Braden scale is used to assess the risk of pressure ulcers in patients. A score of 20 indicates that the patient is not at risk for pressure ulcers. However, preventive measures can still be taken to maintain skin health and prevent future risk.
- Skin Assessment: Regular head-to-toe skin assessments should be performed to monitor for any signs of pressure ulcers or skin breakdown 2.
- Support Surfaces: The use of support surfaces such as visco-elastic foam mattresses or static air overlay mattresses can help reduce the risk of pressure ulcers 3.
- Repositioning: Regular repositioning of the patient can help reduce pressure on vulnerable areas and prevent skin breakdown 2.
- Pressure Reduction: The use of pressure reduction surfaces such as foam overlays or air-cell overlays can help reduce pressure on vulnerable areas 4, 5.
- Individualized Care: Care should be individualized based on the patient's specific needs and risk factors, rather than relying solely on demographic characteristics or diagnoses 2.
Considerations for Preventive Interventions
When considering preventive interventions for a patient with a Braden score of 20, the following factors should be taken into account:
- Braden Scale Score: The patient's Braden scale score should be used to guide preventive interventions, rather than relying solely on demographic characteristics or diagnoses 6, 2.
- Skin Health: The patient's skin health should be monitored regularly to identify any signs of skin breakdown or pressure ulcers 2.
- Support Surfaces: The use of support surfaces such as visco-elastic foam mattresses or static air overlay mattresses can help reduce the risk of pressure ulcers 3.
- Cost-Effectiveness: The cost-effectiveness of preventive interventions should be considered, particularly for patients who are not at high risk for pressure ulcers 4.