BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK

Patient Rm# _______ Age _______ Gender _______ Student’s Name: ______________________________________ Date: _________________
Diagnosis ____________________________________ ____________________________________ ____________________________________ SCORE
1. Completely Limited: 2. Very Limited: 3. Slightly Limited:
4. No Impairment:
Unresponsive (does not moan, flinch, or Responds only to painful stimuli. Responds to verbal commands, but
SENSORY PERCEPTION Responds to verbal
grasp) to painful stimuli, due to Cannot communicate discomfort except cannot always communicate
Ability to respond commands. Has no sensory
diminished level of consciousness or by moaning or restlessness. discomfort or the need to be turned.
meaningfully to pressure- deficit which would limit ability
sedation. OR OR has a sensory impairment which OR has some sensory impairment
related discomfort. to feel or voice pain or
Limited ability to feel pain over most of limits the ability to feel pain or which limits ability to feel pain or
discomfort.
body surface. discomfort over 1/2 of body. discomfort in 1 or 2 extremities.

1. Constantly Moist:
2. Moist: 3. Occasionally Moist: 4. Rarely Moist:
MOISTURE Skin is kept moist almost constantly by
Skin is often, but not always moist. Skin is occasionally moist, requiring Skin is usually dry, linen
Degree to which skin is perspiration, urine, etc. Dampness is
Linen must be changed at least once a an extra linen change approximately requires changing only at
exposed to moisture. detected every time patient is moved or
shift. once a day. routine intervals.
turned.

2. Chairfast: 3. Walks Occasionally: 4. Walks Frequently:

Ability to walk severely limited or non- Walks occasionally during day, but Walks outside room at least
ACTIVITY 1. Bedfast:
existent. Cannot bear own weight for very short distances, with or twice a day and inside room
Degree of physical activity. Confined to bed.
and/or must be assisted into chair or without assistance. Spends majority at least once every 2 hours
wheelchair. of each shift in bed or chair. during waking hours.

2. Very Limited:
1. Completely Immobile: 3. Slightly Limited: 4. No Limitation:
MOBILITY Makes occasional slight changes in
Does not make even slight changes in Makes frequent though slight Makes major and frequent
Ability to change and control body or extremity position but unable to
body or extremity position without changes in body or extremity changes in position without
body position. make frequent or significant changes
assistance. position independently. assistance.
independently.

1. Very Poor: 2. Probably Inadequate: 3. Adequate:

4. Excellent:
Never eats a complete meal. Rarely Rarely eats a complete meal and Eats over half of most meals. Eats a
Eats most of every meal.
eats more than 1/3 of any food offered. generally eats only about 1/2 of any total of 4 servings of protein (meat,
Never refuses a meal.
Eats 2 servings or less of protein (meat food offered. Protein intake includes dairy products) per day.
NUTRITION Usually eats a total of 4 or
or dairy products) per day. Takes fluids only 3 servings of meat or dairy Occasionally will refuse a meal, but
Usual food intake pattern. more servings of meat and
poorly. Does not take a liquid dietary products per day. Occasionally will take will usually take a supplement when
dairy products. Occasionally
supplement OR is NPO and/or a dietary supplement. OR receives less offered. OR is on a tube feeding or
eats between meals. Does
maintained on clear liquids or IV’s for than optimum amount of liquid diet or TPN regimen, which probably
not require supplementation.
more than 5 days. tube feeding. meets most of nutritional needs.

1. Problem:
2. Potential Problem:
Requires moderate to maximum
Moves feebly or requires minimum 3. No Apparent Problem:
assistance in moving. Complete lifting
assistance. During a move skin Moves in bed and in chair
without sliding against sheets is
probably slides to some extent against independently and has sufficient
FRICTION & SHEAR impossible. Frequently slides down in
sheets, chair, restraints or other muscle strength to lift up completely
bed or chair, requiring frequent
devices. Maintains relatively good during move. Maintains good
repositioning with maximum assistance.
position in chair or bed most of the time position in bed or chair at aid times.
Spasticity, contractures or agitation
but occasionally slides down.
leads to almost constant friction.

TOTAL
INTERPRETATION OF SCORE: Check the appropriate box below and indicate what the patient is at risk for. SCORE
Based on the Braden score, this patient is: 19-23 No Risk 15-18 At Risk 13-14 Mod Risk 10-12 High Risk ≤ Very High Risk
for _______________________________