BRADEN SCALE – For Predicting Pressure Sore Risk

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

DATE OF ASSESS ?

RISK FACTOR SCORE/DESCRIPTION 1 2 3 4

SENSORY PERCEPTION Ability to respond meaningfully to pressure-related discomfort

1. COMPLETELY LIMITED – Unresponsive (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.

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.

3. SLIGHTLY LIMITED – Responds to verbal 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.

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

MOISTURE Degree to which skin is exposed to moisture

1. CONSTANTLY MOIST– Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.

2. OFTEN MOIST – Skin is often but not always moist. Linen must be changed at least once a shift.

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.

ACTIVITY Degree of physical activity

1. BEDFAST – Confined to bed.

2. CHAIRFAST – Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair.

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.

4. WALKS FREQUENTLY– Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours.

MOBILITY Ability to change and control body position

1. COMPLETELY IMMOBILE – Does not make even slight changes in body or extremity position without assistance.Read the following scenario and complete the Braden Scale worksheet. Discuss why you scored the Braden the way you did and add insights that you gained by completing the activity. Discuss the scoring with your classmates and any differences that you have in the ratings. Make sure to attach your completed Braden to your post.
Mr. Smith is an 87 year old male who suffered a stroke 5 years ago. He has been bedridden since the stroke. His wife is no longer able to care for him at home. Because of this, Mr. Smith has been admitted to the long term care facility. He has lost 27 pounds over the last 6 months.
He requires assistance with feeding and his appetite is poor. He frequently falls asleep during meals making it difficult for him to eat more than half of the food on his plate. He is incontinent of urine and stool. He is able to follow commands, but is unable to communicate verbally.
Physical therapy will begin working with Mr. Smith to increase his muscle strength. The goal is for him to be able to change his position in bed and in the wheel chair.
Current medications are:
4 ounces of ensure after every meal
Metoprolol 100mg every morning
Furosemide 40mg every morning
Colace 100mg every morning
Gemfibrozil 600mg BID
Braden Scale: