BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK
Evaluator's Name_____________________________________ Date of Assessment
SEVERE RISK: Total Score < 9 HIGH RISK: Total Score 10-12
MODERATE RISK: Total Score 13-14 MILD RISK: Total Score 15-18
© Copyright Barbara Braden and Nancy Bergstrom, 1988 All rights reserved. Used with permission
Total Score
SENSORY PERCEPTION
ability to respond meaningfully to pressure-related
discomfort
MOISTURE
degree to which skin is
exposed to moisture
ACTIVITY
degree of physical activity
MOBILITY
ability to change and control body position
NUTRITION
usual food intake pattern
FRICTION & SHEAR
1. Completely Limited
Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of con-sciousness or sedation.
OR
limited ability to feel
pain over most of body
1. Constantly Moist
Skin is kept moist almost
constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.
1. Bedfast
Confined to bed.
1. Completely Immobile
Does not make even slight changes in body or extremity position without assistance
1. Very Poor
Never eats a complete meal. Rarely eats more than a of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid
dietary supplement
OR
is NPO and/or maintained on clear liquids or IV's for more
than 5 days.
1. Problem
Requires moderate to maximum assistance in moving. Complete lifting without sliding against
sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or
agitation leads to almost
constant friction
2. Very Limited
Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness
OR
has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body.
2. Very Moist
Skin is often, but not always moist. Linen must be changed at least once a shift.
2. Chairfast
Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into
chair or wheelchair.
2. Very Limited
Makes occasional slight changes in body or extremity position but
unable to make frequent or significant changes independently.
2. Probably Inadequate
Rarely eats a complete meal and generally eats only about 2 of any food offered. Protein intake
includes only 3 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
2. Potential Problem
Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most
of the time but occasionally slides down.
3. Slightly Limited
Responds to verbal commands, but cannot always communicate discomfort or the need to be turned.
OR
has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.
3. Occasionally Moist:
Skin is occasionally moist, requiring an extra linen change approximately
once a day.
3. Walks Occasionally
Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair
3. Slightly Limited
Makes frequent though slight changes in body or extremity position independently.
3. Adequate
Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products per day.
Occasionally will refuse a meal, but will usually take a supplement when offered
OR
is on a tube feeding or TPN regimen which probably meets most of nutritional needs
3. No Apparent Problem
Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.
4. No Impairment
Responds to verbal
commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort..
4. Rarely Moist
Skin is usually dry, linen only requires changing at routine intervals.
4. Walks Frequently
Walks outside room at least twice a day and inside room at least once every two hours during waking hours
4. No Limitation
Makes major and frequent changes in position without assistance.
4. Excellent
Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and
dairy products. Occasionally eats between meals. Does not require supplementation.
