Braden Scale for Predicting Pressure Ulcer Risk

Patient: __________________________ Date of Assessment / / / /

Sensory 1. Completely limited: 2. Very limited: Responds 3. Slightly limited: 4. No impairment:
perception Unresponsive (does not only to painful stimuli. Responds to verbal Responds to verbal
Ability to respond moan, flinch, or grasp) to Cannot communicate commands but cannot commands. Has no sensory
meaningfully to painful stimuli, due to discomfort except by always communicate deficit which would limit
pressure-related diminished level of moaning or restlessness, discomfort or need to be ability to feel or voice pain
discomfort consciousness or sedation, OR turned, or discomfort.
OR has a sensory impairment OR
limited ability to feel pain which limits the ability to has some sensory
over most of body surface. feel pain or discomfort impairment which limits
over 1/2 of body. ability to feel pain or
discomfort in 1 or 2
extremities. ___ ___ ___ ___
Moisture 1. Constantly moist: Skin 2. Moist: Skin is often but 3. Occasionally moist: 4. Rarely moist: Skin is
Degree to which is kept moist almost not always moist. Linen Skin is occasionally usually dry; linen requires
skin is exposed constantly by perspiration, must be changed at least moist, requiring an extra changing only at routine
to moisture urine, etc. Dampness is once a shift. linen change intervals.
detected every time patient approximately once a
is moved or turned. day. ___ ___ ___ ___
Activity 1. Bedfast: Confined to bed. 2. Chairfast: Ability to 3. Walks occasionally: 4. Walks frequently: Walks
Degree of walk severely limited or Walks occasionally outside the room at least
physical activity nonexistent. Cannot bear during day but for very twice a day and inside room
own weight and/or must be short distances, with or at least once every 2 hours
assisted into chair or without assistance. during waking hours.
wheel chair. Spends majority of each
shift in bed or chair. ___ ___ ___ ___
Mobility 1. Completely immobile: 2. Very limited: Makes 3. Slightly limited: 4. No limitations: Makes
Ability to change Does not make even slight occasional slight changes Makes frequent though major and frequent changes
and control body changes in body or in body or extremity slight changes in body in position without
position extremity position without position but unable to or extremity position assistance.
assistance. make frequent or independently.
significant changes
independently. ___ ___ ___ ___
Nutrition 1. Very poor: Never eats a 2. Probably inadequate: 3. Adequate: Eats over 4. Excellent: Eats most of
Usual food intake complete meal. Rarely eats Rarely eats a complete half of most meals. Eats every meal. Never refuses a
pattern more than 1/3 of any food meal and generally eats a total of 4 servings of meal. Usually eats a total of
offered. Eats 2 servings or only about 1/2 of any food protein (meat, dairy 4 or more servings of meat
less of protein (meat or dairy offered. Protein intake products) each day. and dairy products.
products) per day. Takes includes only 3 servings of Occasionally will refuse Occasionally eats between
fluids poorly. Does not take meat or dairy products per a meal, but will usually meals. Does not require
a liquid dietary supplement, day. Occasionally will take take a supplement if supplementation.
OR a dietary supplement, offered,
is NPO[1] and/or maintained OR OR
on clear liquids or IV[2] for receives less than is on a tube feeding or
more than 5 days. optimum amount of liquid TPN[3] regimen, which
diet or tube feeding. probably meets most of
nutritional needs. ___ ___ ___ ___
Friction and 1. Problem: Requires 2. Potential problem: 3. No apparent
shear moderate to maximum Moves feebly or requires problem: Moves in bed
assistance in moving. minimum assistance. and in chair
Complete lifting without During a move skin independently and has
sliding against sheets is probably slides to some sufficient muscle
impossible. Frequently extent against sheets, strength to lift up
slides down in bed or chair, chair, restraints, or other completely during move.
requiring frequent devices. Maintains Maintains good position
repositioning with maximum relatively good position in in bed or chair at all
assistance. Spasticity, chair or bed most of the times.
contractures, or agitation time but occasionally
leads to almost constant slides down.
friction. ___ ___ ___ ___
© Copyright Barbara Braden and Nancy Bergstrom, 1988

Note: (Braden, 2001)

15 – 18 = At Risk
13 – 14 = Moderate Risk
10 – 12 = High Risk
< 9 = Very High Risk

Assessment Schedule:
Very High to High Risk = minimum monthly
Moderate Risk = q3 months
Low/No Risk = q6 months
Consider other resident factors that will increase risks, e.g. advanced age, uncontrolled pain, underlying disease conditions, low albumin and HGB