BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK

Patient’s Name Evaluator’s Name Date of Assessment

RISK FACTOR SCORE / DESCRIPTION 1 2 3 4

SENSORY PERCEPTION 1. Completely Limited 2. Very Limited 3. Slightly Limited 4. No Impairment
Unresponsive (does not moan, Responds only to painful stimuli. Responds to verbal commands, Responds to verbal
ability to respond flinch, or grasp) to painful Cannot communicate discomfort but cannot always communicate commands. Has no sensory
meaningfully to pressure- stimuli, due to diminished level except by moaning or discomfort or the need to be deficit which would limit ability
related discomfort of consciousness or sedation restlessness, turned, to feel or voice pain or
OR OR OR discomfort.
limited ability to feel pain over has a sensory impairment which has some sensory impairment
most of body. limits the ability to feel pain or which limits ability to feel pain or
discomfort over ½ of body. discomfort in 1 or 2 extremities.
MOISTURE 1. Constantly Moist 2. Very Moist 3. Occasionally Moist 4. Rarely Moist
Skin is kept moist almost Skin is often, but not always Skin is occasionally moist, Skin is usually dry; linen only
degree to which skin is constantly by perspiration, moist. Linen must be changed at requiring an extra linen change requires changing at routine
exposed to moisture urine, etc. Dampness is least once a shift. approximately once a day. intervals.
detected every time patient is
moved or turned.
ACTIVITY 1. Bedfast 2. Chairfast 3. Walks Occasionally 4. Walks Frequently
Confined to bed. Ability to walk severely limited or Walks occasionally during day, Walks outside room at least
degree of physical activity non-existent. Cannot bear own but for very short distances, with twice a day and inside room at
weight and/or must be assisted or without assistance. Spends least once every two hours
into chair or wheelchair. majority of each shift in bed or during waking hours.
chair.
MOBILITY 1. Completely Immobile 2. Very Limited 3. Slightly Limited 4. No Limitation
Does not make even slight Makes occasional slight changes Makes frequent though slight Makes major and frequent
ability to change and control changes in body or extremity in body or extremity position but changes in body or extremity changes in position without
body position position without assistance. unable to make frequent or position independently. assistance.
significant changes.
independently.
NUTRITION 1. Very Poor 2. Probably Inadequate 3. Adequate 4. Excellent
Never eats a complete meal. Rarely eats a complete meal and Eats over half of most meals. Eats most of every meal. Never
usual food intake pattern Rarely eats more than ⅓ of generally eats only about ½ of Eats a total of 4 servings of refuses a meal. Usually eats a
any food offered. Eats 2 any food offered. Protein intake protein (meat, dairy products) per total of 4 or more servings of
servings or less of protein includes only 3 servings of meat day. Occasionally will refuse a meat and dairy products.
(meat or dairy products) per or dairy products per day. meal, but will usually take a Occasionally eats between
day. Takes fluids poorly. Does Occasionally will take a dietary supplement when offered, meals. Does not require
not take a liquid dietary supplement, OR supplementation.
supplement, OR is on a tube feeding or TPN
OR receives less than optimum regimen which probably meets
is NPO and/or maintained on amount of liquid diet or tube most of nutritional needs.
clear liquids or IVs for more feeding.
than 5 days.
FRICTION & SHEAR 1. Problem 2. Potential Problem 3. No Apparent Problem
Requires moderate to Moves feebly or requires Moves in bed and in chair
maximum assistance in minimum assistance. During a independently and has sufficient
moving. Complete lifting move skin probably slides to muscle strength to lift up
without sliding against sheets some extent against sheets, completely during move.
is impossible. Frequently slides chair, restraints or other devices. Maintains good position in bed or
down in bed or chair, requiring Maintains relatively good position chair.
frequent repositioning with in chair or bed most of the time
maximum assistance. but occasionally slides down.
Spasticity, contractures or
agitation leads to almost
constant friction.
Very High Risk: Total Score 9 or less. High Risk: Total Score 10-12. 0
Grand Total Score
Moderate Risk: Total Score 13-14. Mild Risk: Total Score 15-18.
No Risk: Total Score 19-23.