The Braden Q Scale

Intensity and Duration of Pressure

Score
1. Completely immobile: 2. Very Limited: 3. Slightly Limited: 4. No Limitations:
Mobility Does not make even slight Makes occasional slight changes in Makes frequent though slight Makes major and frequent
The ability to changes in body or extremity body or extremity position but changes in body or extremity changes in position without
change and position without assistance. unable to completely turn self position independently. assistance.
control body independently.
position
4. All patients too young to
1. Bedfast: 2. Chair fast: 3. Walks Occasionally: ambulate OR walks
Activity Confined to bed Ability to walk severely limited or Walks occasionally during day, frequently: Walks outside
The degree of nonexistent. Cannot bear own but for very short distances, the room at least twice a day
physical activity weight and/or must be assisted in with or without assistance. and inside room at least once
to chair or wheelchair. Spends majority of each shift in every 2 hours during waking
bed or chair. hours.
Sensory 1. Completely Limited: 2. Very Limited: 3. Slightly Limited: 4. No Impairment:
Unresponsive (does not Responds only to painful stimuli. Responds to verbal commands, Responds to verbal
Perception moan, flinch, or grasp) to Cannot communicate discomfort but cannot always commands. Has no sensory
The ability to
painful stimuli, due to except by moaning or restlessness communicate discomfort or deficit, which limits ability
respond in a
diminished level of OR has sensory impairment which need to be turned OR has some to feel or communicate pain
developmentally
consciousness or sedation limits the ability to feel pain or sensory impairment which or discomfort.
appropriate way
OR limited ability to feel discomfort over ½ of body. limits ability to feel pain or
to pressure-
pain over most of body discomfort in 1 or 2
related
surface. extremities.
discomfort
Tolerance of the Skin and Supporting Structure
1. Constantly Moist: 2. Very Moist: 3. Occasionally Moist: 4. Rarely Moist:
Moisture Skin is kept moist almost Skin is often, but not always moist. Skin is occasionally moist, Skin is usually dry,
Degree to which constantly by perspiration, Linen must be changed at least requiring linen change every 12 routine diaper changes,
skin is exposed to urine, drainage, etc. every 8 hours. hours. linen only requires
moisture Dampness is detected every changing every 24 hours.
time patient is moved or
turned.
Friction - 1. Significant Problem: 2. Problem: 3. Potential Problem: 4. No Apparent
Spasticity, contracture, Requires moderate to maximum Moves feebly or requires Problem:
Shear itching or agitation leads to assistance in moving. Complete minimum assistance. During a Able to completely lift
Friction: occurs
almost constant thrashing lifting without sliding against move skin probably slides to some patient during a position
when skin moves
and friction. sheets is impossible. Frequently extent against sheets, chair, change; Moves in bed and
against support
slides down in bed or chair, restraints, or other devices. in chair independently
surfaces
requiring frequent repositioning Maintains relative good position and has sufficient muscle
Shear: occurs
with maximum assistance. in chair or bed most of the time strength to lift up
when skin and
but occasionally slides down. completely during move.
adjacent bony
Maintains good position
surface slide
in bed or chair at all
across one
times.
another
1. Very Poor: 2. Inadequate: 3. Adequate: 4. Excellent:
NPO and/or maintained on Is on liquid diet or tube Is on tube feedings or TPN, which Is on a normal diet
clear liquids, or IVs for more feedings/TPN which provide provide adequate calories and providing adequate
than 5 days OR inadequate calories and minerals minerals for age OR eats over half calories for age. For
Nutrition Albumin <2.5 mg/dl OR for age OR Albumin <3 mg/dl OR of most meals. Eats a total of 4 example: eats/drinks most
Usual food Never eats a complete meal. rarely eats a complete meal and servings of protein (meat, dairy of every meal/feeding.
intake pattern Rarely eats more than ½ of generally eats only about ½ of any products) each day. Occasionally Never refuses a meal.
any food offered. Protein food offered. Protein intake will refuse a meal, but will usually Usually eats a total of 4 or
intake includes only 2 includes only 3 servings of meat or take a supplement if offered. more servings of meat
servings of meat or dairy dairy products per day. and diary products.
products per day. Takes Occasionally will take a dietary Occasionally eats
fluids poorly. Does not take supplement. between meals. Does not
a liquid dietary supplement. require supplementation.
1. Extremely 2. Compromised: 3. Adequate: 4. Excellent:
Tissue Compromised: Normotensive; Normotensive; Normotensive,
Perfusion Hypotensive (MAP Oxygen saturation may be <95 % Oxygen saturation may be <95 % Oxygen saturation >95%;
<50mmHg; <40 in a OR hemoglobin may be < 10 OR hemoglobin may be < 10 Normal Hemoglobin ; &
and newborn) OR the patient mg/dl OR capillary refill may be mg/dl OR capillary refill may be Capillary refill < 2
Oxygenation does not physiologically > 2 seconds; > 2 seconds; seconds.
tolerate position changes. Serum pH is < 7.40. Serum pH is normal.
Total:

From Curley, M.A.Q., Razmus, I.S., Roberts, K.E., Wypij, D. Predicting Pressure Ulcer Risk in
Pediatric Patients: The Braden Q Scale. Nursing Research. 52(1):22-33, January/February 2003.