ETABLE 13-1

eTABLE 13-1

BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK

Evaluators Name _______________________________________

Patient Name ____________________________________

POINT VALUE 1 2 3 4

DATE OF ASSESSMENT AND SCORE

Sensory Perception: Ability to respond meaningfully to pressure-related discomfort

Completely limited: unresponsive (does not moan, inch, or grasp) to painful stimuli, because of diminished level of consciousness or sedation OR limited ability to feel pain over most of body Very limited: responds only to painful stimuli; cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment that limits the ability to feel pain or discomfort over half of body Slightly limited: responds to verbal commands, but cannot always communicate discomfort or the need to be turned OR has some sensory impairment that limits ability to feel pain or discomfort in one or two extremities No impairment: responds to verbal commands; has no sensory decit that would limit ability to feel or to voice pain or discomfort

Moisture: Degree to which skin is exposed to moisture

Constantly moist: skin is kept moist almost constantly by perspiration, urine, etc.; dampness is detected every time patient is moved or turned Very moist: skin is often, but not always, moist; linen must be changed at least once per shift Occasionally moist: skin is occasionally moist, requiring an extra linen change approximately once per day Rarely moist: skin is usually dry; linen only requires changing at routine intervals

Activity: Degree of physical activity

Bedfast: conned to bed Chairfast: ability to walk severely limited or nonexistent; cannot bear own weight and/or must be assisted into chair or wheelchair Walks occasionally: walks occasionally during day, but for very short distances, with or without assistance; spends most of each shift in bed or chair Walks frequently: walks outside room at least twice per day and inside room at least once every 2 hours during waking hours

Mobility: Ability to change and control body position

Completely immobile: does not make even slight changes in body OR extremity position without assistance Very limited: makes occasional slight changes in body or extremity position but unable to make frequent OR signicant changes independently Slightly limited: makes frequent although slight changes in body OR extremity position independently No limitation: makes major and frequent changes in position without assistance

Nutrition: Usual food intake pattern

Very poor: never eats a complete meal; rarely eats more than 12 of any food offered; eats two servings or less of protein (meat or dairy products) per day; takes uids poorly; does not take a liquid dietary supplement or is NPO and/or maintained on clear liquids or IVs for more than 5 days Probably inadequate: rarely eats a complete meal and generally eats only about 12 of any food offered; protein intake includes only three servings of meat or dairy products per day; occasionally will take a dietary supplement or receives less than optimum amount of liquid diet or tube feeding Adequate: eats over half of most meals; eats four servings of protein (meat or dairy products) per day; occasionally will refuse a meal, but will usually take a supplement when offered or is on a tube feeding or parenteral nutrition regimen that probably meets most of nutritional needs Excellent: eats most of every meal; never refuses a meal; eats four or more servings of protein (meat or dairy products); occasionally eats between meals; does not require supplementation

Continued

Copyright 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983 by Mosby, Inc., an affiliate of Elsevier Inc.

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BRADEN SCALE FOR PREDICTING PRESSURE SORE RISKcontd
Evaluators Name _______________________________________

eTABLE 13-1

Patient Name ____________________________________

POINT VALUE 1 Friction and Shear 2 3 4

DATE OF ASSESSMENT AND SCORE

Problem: requires moderate Potential problem: No apparent problem: to maximum assistance in moves feebly or requires moves in bed and in moving; complete lifting minimum assistance; chair independently and without sliding against during a move, skin has sufcient muscle sheets is impossible; probably slides to some strength to lift up frequently slides down extent against sheets, completely during move; in bed or chair, requiring chair, restraints, or maintains good position frequent repositioning other devices; maintains in bed or chair with maximum assistance; relatively good position spasticity, contractures, in chair or bed most of or agitation lead to almost the time but occasionally constant friction slides down Scoring: To obtain a patients pressure ulcer risk assessment score, add the numeric scores for the factors in each of the six subscales (sensory perception, moisture, activity, mobility, nutrition, and friction and shear) to obtain the total score. Scores can range from 6 to 23. The lower the numeric score, the higher the patients predicted risk of developing a pressure ulcer. Incremental changes in the score indicate the level of risk: no risk (19 to 23), at risk (15 to 18), moderate risk (13 to 14), high risk (10 to 12), and very high risk (9 or below).
From Braden B, Bergstrom N: Predictive validity of the Braden scale for pressure sore risk in a nursing home population, Res Nurs Health 17:459, 1994. Copyright Barbara Braden and Nancy Bergstrom. All rights reserved. Available at www.bradenscale.com.

Copyright 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983 by Mosby, Inc., an affiliate of Elsevier Inc.