CHRISTIAN HOME HEALTH CARE

BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK

Patient’s Name Evaluator’s Name Date of Assessment
SENSORY PERCEPTION 1. Completely Limited 2. Very Limited 3. Slightly Limited 4. No Impairment
ability to respond Unresponsive (does not Responds only to painful Responds to verbal Responds to verbal
meaningfully to pressure- moan, flinch, or grasp) to stimuli. Cannot communicate commands, but cannot commands. Has no
related painful stimuli, due to discomfort except by moaning always communicate sensory deficit which
discomfort diminished level of or discomfort or the need to would limit ability to
consciousness or sedation restlessness be feel or voice pain or
OR OR turned discomfort.
limited ability to feel pain has a sensory impairment OR
over most of body. which limits the ability to feel has some sensory
pain or discomfort over ½ of impairment which limits
body. ability to feel pain or
discomfort in 1 or 2
extremities.
MOISTURE 1. Constantly Moist 2. Very Moist 3. Occasionally Moist 4. Rarely Moist
degree to which skin is Skin is kept moist almost Skin is often, but not always Skin is occasionally moist, Skin is usually dry,
exposed to moisture constantly by perspiration, moist. Linen must be changed requiring an extra linen linen only requires
urine, etc. Dampness is at least once a shift. change approximately changing at routine
detected every time patient once a day. intervals.
is moved or turned.
ACTIVITY 1. Bedfast 2. Chairfast 3. Walks Occasionally 4. Walks Frequently
degree of physical activity Confined to bed. Ability to walk severely limited Walks occasionally during Walks outside room at
or non-existent. Cannot bear day, but for very short least twice a day and
own weight and/or must be distances, with or without inside room at least
assisted assistance. Spends once every two hours
into chair or wheelchair. majority of each shift in during waking hours.
bed or chair.
MOBILITY 1. Completely Immobile 2. Very Limited 3. Slightly Limited 4. No Limitation
ability to change and Does not make even slight Makes occasional slight Makes frequent though Makes major and
control changes in body or changes in body or extremity slight changes in body or frequent changes in
body position extremity position without position but unable to make extremity position position without
assistance. frequent or independently. assistance.
significant changes
independently.

NUTRITION 1. Very Poor 2. Probably Inadequate 3. Adequate 4. Excellent

usual food intake pattern Never eats a complete Rarely eats a complete meal Eats over half of most Eats most of every
meal. Rarely eats more than and meals. Eats a total of 4 meal. Never refuses a
⅓ of any food offered. Eats generally eats only about ½ of servings of protein (meat, meal. Usually eats a
2 any food offered. Protein intake dairy products) per total of 4 or more
servings or less of protein includes only 3 servings of day. Occasionally will servings of meat and
(meat or dairy products) per meat refuse a meal, but will dairy products.
day. Takes fluids poorly. or dairy products per day. usually take a supplement Occasionally eats
Does Occasionally will take a dietary when offered between meals. Does
not take a liquid dietary supplement OR not require
supplement OR is on a tube feeding or TPN supplementation.
OR receives less than optimum regimen which probably
is NPO and/or maintained on amount of liquid diet or tube meets most of nutritional
clear liquids or IVs for more feeding. needs.
than 5 days.
FRICTION & SHEAR 1. Problem 2. Potential Problem 3. No Apparent Problem

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Requires moderate to Moves feebly or requires Moves in bed and in chair
maximum assistance in minimum assistance. During a independently and has
moving. Complete lifting move skin probably slides to sufficient muscle strength
without sliding against some extent against sheets, to lift up completely during
sheets is impossible. chair, restraints or other move. Maintains good
Frequently slides down in devices. position in bed or
bed or chair, requiring Maintains relatively good chair.
frequent repositioning with position
maximum assistance. in chair or bed most of the time
Spasticity, contractures or but occasionally slides down.
agitation leads to almost
constant friction.
The Braden Scale is used as a risk assessment tool for pressure ulcers of the skin. Total Score
Low risk 15-16 Moderate risk 13-14 High risk 12 or less

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Protocols by Level of Risk

AT RISK (15-18)* MANAGE MOISTURE

FREQUENT TURNING USE COMMERCIAL MOISTURE BARRIER

MAXIMAL REMOBILIZATION USE ABSORBANT PADS OR DIAPERS
PROTECT HEELS THAT
MANAGE MOISTURE, NUTRITION WICK & HOLD MOISTURE
AND FRICTION AND SHEAR ADDRESS CAUSE IF POSSIBLE
PRESSURE-REDUCTION SUPPORT OFFER BEDPAN/URINAL AND GLASS OF
SURFACE WATER IN CONJUNCTION WITH TURNING
IF BED OR CHAIR-BOUND SCHEDULES
*If other major risk factors are present
(advanced age, fever, poor dietary intake
or protein, diastolic pressure below 60,
hemodynamic instability)
Advance to next level of risk

MODERATE RISK (13-14)* MANAGE NUTRITION

TURNING SCHEDULE INCREASE PROTEIN INTAKE

USE FOAM WEDGES FOR 30! INCREASE CALORIE INTAKE TO SPARE
LATERAL PROTEINS.
POSITIONING SUPPLEMENT WITH MULTI-VITAMIN
PRESSURE-REDUCTION SUPPORT (SHOULD HAVE VIT A, C & E)
SURFACE ACT QUICKLY TO ALLEVIATE DEFICITS
MAXIMAL REMOBILIZATION CONSULT DIETITIAN
PROTECT HEELS
MANAGE MOISTURE, NUTRITION
AND FRICTION AND SHEAR
*If other major risk factors present,
Advance to next level of risk

HIGH RISK (10-12) MANAGE FRICTION & SHEAR

INCREASE FREQUENCY OF TURNING ELEVATE HOB NO MORE THAN 30!

SUPPLEMENT WITH SMALL SHIFTS USE TRAPEZE WHEN INDICATED
PRESSURE REDUCTION SUPPORT USE LIFT SHEET TO MOVE PATIENT
SURFACE PORTECT ELBOWS AND HEELS IF BEING
USE FOAM WEDGES FOR 30! EXPOSED TO FRICTION
LATERAL
POSITIONING
MAXIMAL REMOBILIZATION
PROTECT HEELS
MANAGE MOISTURE, NUTRITION
AND FRICTION AND SHEAR

VERY HIGH RISK (9 OR below) OTHER GENERAL CARE ISSUES

ALL OF THE ABOVE NO MASSAGE OF REDDENED BONY

+ PROMINENCES
USE PRESSURE-RELIEVING SURFACE NO DONUT TYPE DEVICES
IF MAINTAIN GOOD HYDRATION
PATIENT HAS INTRACTABLE PAIN AVOID DRYING THE SKIN
OR
SEVERE PAIN EXACERBATED BY
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TURNING
OR
ADDITIONAL RISK FACTORS
*low air loss beds do not substitute for
turning
schedules
© Barbara Braden, 2001