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Braden Scale Assessment Form

By Lauren-Ice Mar 22, 2015 834 Words
BRADEN SCALE – For Predicting Pressure Sore Risk
DATE OF
ASSESS 

SEVERE RISK: Total score 9 HIGH RISK: Total score 10-12
MODERATE RISK: Total score 13-14
MILD RISK: Total score 15-18

RISK FACTOR

SCORE/DESCRIPTION

SENSORY
PERCEPTION

1. COMPLETELY
LIMITED – Unresponsive

Ability to respond
meaningfully to
pressure-related
discomfort

(does not moan, flinch, or
grasp) to painful stimuli,
due to diminished level of
consciousness or
sedation,
OR
limited ability to feel pain
over most of body
surface.

MOISTURE

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.

Degree to which
skin is exposed to
moisture

ACTIVITY
Degree of physical
activity

MOBILITY
Ability to change

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 ½ of body.
2. OFTEN 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 nonexistent. Cannot
bear own weight and/or
must be assisted into
chair or wheelchair.

and control body
position

1. COMPLETELY
IMMOBILE – Does not
make even slight changes
in body or extremity
position without
assistance.

2. VERY LIMITED –
Makes occasional slight
changes in body or
extremity position but
unable to make frequent
or significant changes
independently.

NUTRITION

1. VERY POOR – Never

Usual food intake
pattern

eats a complete meal.
Rarely eats more than 1/3
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 NPO1 and/or
maintained on clear
liquids or IV2 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. PROBABLY
INADEQUATE – Rarely

1

NPO: Nothing by
mouth.
IV: Intravenously.
3
TPN: Total
parenteral
nutrition.
2

FRICTION AND
SHEAR

TOTAL
SCORE
ASSESS

eats a complete meal and
generally eats only about
½ 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.

1

3. SLIGHTLY LIMITED –
Responds to verbal

3

4

4. NO IMPAIRMENT –
Responds to verbal
commands. Has no
sensory deficit which
would limit ability to feel
or voice pain or
discomfort.

commands but cannot
always communicate
discomfort or 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.

4. RARELY MOIST – Skin
is usually dry; linen only
requires changing at
routine intervals.

3. WALKS

4. 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.

outside the room at least
twice a day and inside
room at least once every
2 hours during waking
hours.

3. ADEQUATE – Eats

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.

OCCASIONALLY – Walks

FREQUENTLY– Walks

4. NO LIMITATIONS –
Makes major and
frequent changes in
position without
assistance.

over half of most meals.
Eats a total of 4 servings
of protein (meat, dairy
products) each day.
Occasionally refuses a
meal, but will usually take
a supplement if offered,
OR
is on a tube feeding or
3
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 at all times.

Total score of 12 or less represents HIGH RISK
DATE

EVALUATOR SIGNATURE/TITLE

ASSESS.

DATE

1

/

/

3

/

/

2

/

/

4

/

/

NAME-Last

2

First

Form 3166P BRIGGS, Des Moines, IA 50306 (800) 247-2343 www.BriggsCorp.com R304
PRINTED IN U.S.A

Middle

Attending Physician

EVALUATOR SIGNATURE/TITLE

Record No.

Source: Barbara Braden and Nancy Bergstrom. Copyright, 1988. Reprinted with permission. Permission should be sought to use this tool at www.bradenscale.com

Room/Bed

BRADEN SCALE

Use the form only for the approved purpose. Any use of the form in publications (other than internal policy manuals and training material) or for profit-making ventures requires additional permission and/or negotiation.

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