Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Braden Scale for Predicting Pressure Sore Risk

Patient´s Name __________________

Evaluator´s Name ________________

Date: __________________________

SENSORY PERCEPTION:
the ability to respond to pressure-related discomfort
1. Completly 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
2. Very Limited
Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness,
          OR
has a sensor impairment that limits the ability to feel pain or discomfort over 1/2 of body.
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.
4. No Impairment
Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.
Subtotal:

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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 of body
2. Very 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.
Subtotal:

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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 every 2 hours during waking hours.
Subtotal:

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MOBILITY
ability to change 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.
3. Slightly Limited
Makes frequent though slight changes in body or extremity position independently..
4. No Limitation
Makes major and frequent changes in position without assistance.
Subtotal:

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NUTRITION
usual food intake pattern
1. Very Poor
Never 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 NPO and/or maintained on clear liquids or IVs for more than 5 days
2. Probably Inadequate
Rarely eats a complete meal and generally eats only about 1/2 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.
3. Adequate
Eats over half of most meals. Eats a total of 4 servings of protein (meat or dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered
          OR
is on a tube feeding or TPN regimen, which meets most of nutritional needs.
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.
Subtotal:

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FRICTION AND SHEAR
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 lead to almost constant friction.
2. Potential Problems
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. 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.
Subtotal:

TOTAL: _____________

Note: Individuals with a score of 18 or less are considered to be at risk of developing pressure ulcers.

  • At risk – 15 to 18;
  • Moderate Risk – 13 to 14;
  • High Risk – 10 to 12;
  • Very High Risk – 9 or below.

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