Braden Scale for Predicting Pressure Ulcer Risk

 

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Patient's Name:

Evaluator's Name:

Date of Assessment:

SENSORY PERCEPTION

ability to respond meaningfully to pressure-related discomfort

1. Completely Limited

Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation.

OR

limited ability to feel pain over most of body surface.

2. Very Limited

Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness.

OR

has a sensory impairment which limits the ability to feel pain or discomfort over ½ of the body.

3. Slightly Limited

Responds to verbal commands, but cannot always communicate discomfort or need to be turned.

OR

has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.

4. No Impairment

Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.

MOISTURE

degree to which skin is exposed to moisture

1. Constantly Moist

Skin is kept moist almost constantly by perspiration, urine, etc. Dampness detected every time patient is moved or turned.

2. Very Moist

Skin is often, but not always moist. Linen must be changed at least once a shift.

3. Occasionally Moist

Skin is occasionally moist, requiring an extra linen change approximately once a day.

4. Rarely Moist

Skin is usually dry. Linen only requires changing at routing intervals.

ACTIVITY

degree of physical activity

1. Bedfast

Confined to bed.

2. Chairfast

Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.

3. Walks Occasionally

Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.

4. Walks Frequently

Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours.

MOBILITY

ability to change and control body position

1. Completely Immobile

Does not make even slight changes in body or extremity position without assistance.

2. Very Limited

Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

3. Slightly Limited

Makes frequent though slight changes in body or extremity position independently.

4. No Limitations

Makes major and frequent changes in position without assistance.

NUTRITION

usual food intake pattern

1. Very Poor

Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid or dietary supplement.

OR

Is NPO and/or maintained on clear liquids or IV's for more than 5 days.

2. Probably Inadequate

Rarely eats a complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement.

OR

receives less than optimum amount of liquid diet or tube feeding.

3. Adequate

Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered.

OR

is on a tube feeding or TPN regimen which probably meets most of nutritional needs.

4. Excellent

Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.

FRICTION AND SHEAR

1. Problem

Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction.

2. Potential Problem

Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.

3. No Apparent Problem

Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.

 

 

Scoring:  Score of 16 or below = patient at risk;

Score of 18 or above = patient at low or no risk

 

© Copyright Barbara Braden and Nancy Bergstrom, 1988