Braden Scale for predicting pressure injury risk
Ability to respond
Unresponsive (does not moan, flinch, or
meaningrlully to
pressure-related
discomfort
grasp)
ability
surface.
consciousness or sedation OR limited
to feel pain over most of body
Responds only to painful stimuli.
Cannot
Responds to verbal commands, but
which
over
restlessness OR has a sensory impairment
limits the ability to feel pain or discomfort
1/2 of body.
ffin@m@n@!E@n@n
be
skin is exposed
to moisture
Skin is often, but not always moist. Linen must
changed at least once a shift.
Degree of
Confined to bed
Ability to walk severely limited or nonexistent.
Cannot bear own weight and/or must be assisted
into chair or wheelchair.
detecled
5A
Responds to verbal commands. Has no sensory
sg
EE
to be turned OR has some sensory
impairmenl
pain or discomfort.
bc
which limits ability to feel pain or discomfort in
1 or 2 extremities
Ep
Eo
$F
i:d
Skin is kept moist almost constantly by
perspiration, urine, etc. Dampness is
every time patient is moved or turned.
Degree to which
cannot
extra
Skin is occasionally moist, requiring an
linen change approximately once a day.
Skin is usually dry linen only requires changing
at routine intervals.
3:
9*
qp
nl
Bp
physical activity
W;ffiW
Ability to change and
control body position
very
short distances, with or without assistance.
Spends majority of each shift in bed or chair.
Walks occasionally during the day, but lor
Walks outside the room at least tvvice a day and
inside room at least once every two hours during
waking hours.
9b
le
ep
R..a
Does not make even slight changes in body
or extremity position without assistance.
Makes occasional slight changes in body or extremity
position, but unable to make frequent or significant
changes. independently.
Makes frequent though slight changes in body
or odremity position independently.
Makes major and frequent changes in position
without assistance.
5!
dl
8e
-q.0
AF
i3
d;,ffif;
Usual food
Never eats a complete meal. Rarely eats more
intake pattern
than 1/3 of any food offered. Eats 2 seMngs or
less of protein (meat or ddry products) per day.
Takes fluids poorly. Does nol take a liquid dietary
supplement OR is NPO and/or maintained on
clear liquids or lvs for more than 5 days.
Rarely eats a complete meal and generally eats only
about % of any food offered. Protein intake includes
only 3 servings of meat or ddry products per day.
Occasionally will take a dietary supplement OR
receives less than optimum amount of liquid diet
or tube feeding.
Eats over half of most meals. Eats a total of 4
servings of protein (meat, ddry producls) 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.
Eats most of every meal. Never refuses a meal.
Usually eats a total of 4 or mor€ servings oJ
meat and dairy products per day. Occasionally
eats between meals. Does not require
supplementation.
frE
:3
6_9
E3
b,t
a9
f;i
cO
se
p9
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.
Moves feebly or requires minimum assistance. During
a move, skin probably slides to some extent against
sheets, chair, restraints or other devices. Maintains
relalively good position in chair or bed most of the
time but occasionally slides down.
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.
6b
AR
.Ei
!ts' E.
RE
QbN
t8t,
€is
t-s t
o ht
..:o
a;h
Copyright: Barbara Braden & Nancy Bergstrom, 1988. Ail ights reserved. Resource: www.bradenscale.com
A number of contributing or confounding factors are a/so assoclaled wlth pressure ulcers; the significance of these factors is yet to be elucidated.
sEi
i5s
;!:
p\;
a'r t
ArjoHuntleigh lnc.
GETINGE GROUP
2349 West Lake Street, Addison, lllinois 60101
MAQUET
AruoFruNTLElGl{
GETINGE
GITINGE GROUP
GETINGE CROUP
GETINGT GROUP
www.getingegroup.com
MCVOOO44IOB REVA