Part 3 in a series analyzing the use of the Braden Scale for Predicting Pressure Sore Risk® in the long-term care setting. For Part 1, click here. For Part 2, click here.

A common misconception by nurses is sometimes predicting nutritional status based on a resident's weight. Weight is not always a good predictor of nutritional status. Nutritional status is determined by many factors and by looking at the big picture.

Overview of Nutrition in Wound Care

What is nutrition? Nutrition or nutritional status is the process by which our body obtains food, vitamins, and minerals for proper growth and healing. Nutrition is also needed to maintain health and overall function. Good nutrition is needed for strong bones, teeth, and skin. Poor nutrition or dehydration can put someone at risk for pressure injuries, skin tears, and multiple other issues. As per the Braden Scale for Predicting Pressure Sore Risk®, nutrition can be obtained in several ways, orally (PO), intravenously (IV), or by total parenteral nutrition (TPN). Also, a resident may be allowed nothing by mouth (NPO) because of an upcoming test or procedure, for bowel rest, or if the condition is unstable or doesn’t permit oral intake at the present time (e.g., intubated, sedated).

Braden Scale: Categories of Nutritional Status

The categories of the Braden Scale pertaining to nutrition can be seen below, but similar to the other categories, residents receive a score from 1 to 4, with 1 being very poor and 4 being excellent. It is important to read the definition of the subcategories and gain an understanding of what each subcategory is really saying. Some important points are:

• If a resident is NPO, or is maintained on clear liquids or IV fluids (IVF) for >5 days = very poor nutrition
• If a resident is intermittently refusing tube feeding (TF) or eats only about one half of each meal = probably inadequate nutrition
• If a resident eats most of their meals and/or refuses meals but takes a supplement in place of a meal, or is on regular TF or TPN = adequate nutrition
• For residents to have excellent nutrition, they would be snacking in between meals, never refuse a meal, and not be on a nutritional supplement.

When looking at nutrition, it is also important to take into account laboratory values, specifically albumin and pre-albumin. Additionally, it is important to look at C-reactive protein because if it is elevated, pre-albumin can be falsely low. Looking at weight trends and fluid fluctuations is also important; is the resident on a diuretic? Is the resident weighed consistently on the same scale? At the same time of day? Is the resident eating more? Less? These are all important questions to explore when completing an accurate Braden scale. After examining the big picture and determining that the resident is at risk for poor nutrition, how can we fix this? When completing a Braden Scale, it is important not only to assign a score accurately to each category, but also to look at what interventions should be put into place based on that score. Some things to start with are to determine whether the resident is having a true weight loss or decline. if it is determined that, yes, the resident is losing a significant amount of weight or slowly declining over time, interventions are needed.

• Does the resident have a favorite food? If so, maybe family members can bring it in.
• Consider an evaluation or follow-up with the registered dietitian who can best determine the need for supplements and specific types.
• Determine the cause of their poor appetite:
  • Does the resident dislike the food?
  • Is the resident undergoing chemotherapy or radiation?
  • Would an appetite stimulant or discussion with the provider be appropriate?
  • Difficulties chewing or swallowing?
  • Ill-fitting dentures?
• If the resident is receiving TF, is it causing diarrhea? High residuals? Not well tolerated overall? Other issues with administration of TF?
• Is there a decline in condition overall and/or is the resident approaching end of life? Would a goals of care discussion be appropriate, or a hospice or palliative care consultation?

Although nutrition is just one small part of the Braden Scale, it plays a huge role in the resident's overall health status, ability to heal wounds, and likelihood of acquiring a hospital-acquired pressure injury. It is important to assess and reassess nutritional needs accurately and frequently via the Braden scale and with follow-up and recommendations from a registered dietitian. Early intervention and frequent follow-up on nutritional issues and concerns can definitely lead to more positive outcomes nutritionally and contribute to prevention of pressure injuries.

Note: For anyone who wishes to utilize the Braden Scale in their health care facility, you must request permission to do so. Please visit www.bradenscale.com and complete the Permission Request form.

About the Author

Holly is a board certified gerontological nurse and advanced practice wound, ostomy, and continence nurse coordinator at The Department of Veterans Affairs Medical Center in Cleveland, Ohio. She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately six years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention. She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation. She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible. She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes.