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Braden Risk Assessment Tool: Category Descriptor Score Score Score

The document describes the Braden Risk Assessment Tool which is used to evaluate a patient's risk for developing pressure ulcers. It contains categories including sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each category contains descriptors with associated scores to evaluate the patient's condition and risk level.

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Mohammed
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73 views

Braden Risk Assessment Tool: Category Descriptor Score Score Score

The document describes the Braden Risk Assessment Tool which is used to evaluate a patient's risk for developing pressure ulcers. It contains categories including sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each category contains descriptors with associated scores to evaluate the patient's condition and risk level.

Uploaded by

Mohammed
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Braden Risk Assessment Tool Affix patient identification

label in this box

Date of Assessment
CATEGORY DESCRIPTOR SCORE SCORE SCORE
Sensory Completely Limited: Unresponsive (does not moan, flinch or grasp) to painful stimuli due to 1 1 1
Perception diminished level of consciousness or sedation. OR, limited ability to feel pain over most of body
Ability to surface.
respond Very Limited: Responds to only painful stimuli. Cannot communicate discomfort except by 2 2 2
meaningfully moaning or restlessness; OR has sensory impairment that limits the ability to feel pain or discomfort
to pressure over half of body.
related
Slightly Limited: Responds to verbal commands, but cannot always communicate discomfort or 3 3 3
discomfort
need to be turned; OR, has sensory impairment that limits the ability to feel pain or discomfort in
one or two extremities.
No Impairment: Responds to verbal commands. Has no sensory deficit that would limit ability to 4 4 4
feel or communicate pain or discomfort.
Mobility Completely immobile: Does not make even slight changes in body or extremity position without 1 1 1
Ability to assistance.
change and Very limited: Makes occasional slight changes in body or extremity position but unable to make 2 2 2
maintain own frequent or significant changes independently.
position Slightly limited: Makes frequent though slight changes in body or extremity position independently 3 3 3
No limitations: makes major and frequent changes in position without assistance. 4 4 4
Activity Bedfast: confined to bed (can’t sit at all). 1 1 1
Degree of Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be 2 2 2
physical assisted into chair or wheelchair.
activity Walks occasionally: walks occasionally during day, but for very short distances, with or without 3 3 3
assistance. Spends majority of each shift in bed or chair.
Walks frequently: Walks outside the room at least twice a day and inside room at least once every 4 4 4
2 hours during waking hours.
Moisture Constantly moist: skin is kept moist almost constantly by perspiration, urine, drainage etc. 1 1 1
Degree to Dampness is detected every time patient is moved or turned.
which skin is Very moist: Skin is often, but not always, moist. Linen must be changed at least every 8 hours. Dry 2 2 2
exposed to 2-3 hours at a time
moisture Occasionally moist: Skin is occasionally moist, requiring linen change every 12 hours 3 3 3
Rarely moist: Skin is usually dry, linen only requires changing every 24 hours. 4 4 4
Friction Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding
Shear against sheets is impossible. Frequently slides down in bed or chair, requiring frequent 1 1 1
repositioning with maximum assistance. spasticity, contractures, itching or agitation leads to almost
constant friction
Potential problem: Moves feebly or requires minimum assistance. During a move, skin probably
slides to some extent against sheets, chair, restraint or other devices. Maintains relative good 2 2 2
position in chair or bed most of the time but occasionally slides down.
No apparent problem: Able to completely lift patient during a position change, moves in bed and in
chair independently and has sufficient muscle strength to lift completely during move. Maintains 3 3 3
good position in bed or chair at all times.
Nutrition Very poor: NPO and/or maintained on clear fluids, or IVs for more than 5 days OR never eats a 1 1 1
complete meal. Rarely eats more than 1/3 of any food offered. Protein intake includes only 2
servings of meat or dairy products per day. Takes fluids poorly. Does not take a liquid dietary
supplement.
Inadequate: Is on a liquid diet or tube feedings/TPN, which provide inadequate calories and
minerals for age OR rarely eats a complete meal and generally eats only half of any food offered. 2 2 2
Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a
dietary supplement
Adequate: Is on tube feedings OR eats over half of most meals. Eats a total of 4 servings of 3 3 3
protein each day. Occasionally eats between meals. Does not require supplementation.
Excellent: Is on TPN, which provides adequate calories and minerals for age OR Is on a normal
diet providing adequate calories for age. For example, eats most of every meal. Never refuses a 4 4 4
meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats
between meals. Does not require supplementation.
mild risk- 18-15 moderate risk - 14-13 TOTAL SCORE
high risk - 12-10 severe risk - <9
PATIENTS SCORING 12 OR BELOW SHOULD BE CONSIDERED FOR A DYNAMIC AIR MATTRESS
© Braden & Bergstrom, 1988. Reprinted with permission

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