Bra

den

Sca

le f

or

Pre

dic

ting

Pre

ssur

e U

lcer

Ris

k Category I (Stage I)

Category II(Stage II)

Category III(Stage III)

Category IV(Stage IV)

Unclassified(Unstageable)

Suspected Deep Tissue Injury

© Copyright Barbara Braden and Nancy Bergstrom, 1988 All rights reserved

Caustic Fluids (Stool, Urine, Gastric)Moisture Score Action

1

Continuously moist perineum

• Continuous diarrhea• Continuous urine

1. Immediate cleansing with Baza Cleanse & Protect® Lotion

2. Fecal/Urinary containment

3. If skin is broken, apply a skin protectant barrier such as Critic-Aid® Clear Ointment

4. Re-apply q shift or PRN

2

Very moist perineum

• Frequent diarrhea• Peri-wound exposure

1. Immediate cleansing with Baza Cleanse & Protect Lotion

2. Fecal/Urinary containment

3. If skin is broken, apply a skin protectant barrier such as Critic-Aid Clear Ointment

4. Re-apply q shift or PRN

3

Occasionally moist perineum

• Infrequent diarrhea• Infrequent urine

1. Immediate cleansing with Baza Cleanse & Protect Lotion

2. If skin is broken, apply a skin protectant barrier such as Critic-Aid Clear Ointment

3. Re-apply q shift or PRN

Hig

h R

isk

Low

Ris

k

Non-Caustic Fluids (Sweat)Moisture Score Action

1

Continuously moist skin fold

• Obese • Bedridden

1. Cleanse skin fold area with Bedside-Care® Foam

2. Apply InterDry® Ag Textile

3. Change InterDry Ag q 5 d and PRN

4. Continue to assess daily

2

Very moist skin fold

• Contracture of groin or axilla

• Redundant breast

1. Cleanse skin fold area with Bedside-Care Foam

2. Apply InterDry Ag Textile

3. Change InterDry Ag q 5 d and PRN

4. Continue to assess daily

3

Occasionally moist skin fold

• Braces• Armpits• Back of knees

1. Cleanse skin fold area with Bedside-Care Foam

2. Apply InterDry Ag Textile

3. Change InterDry Ag Textile q 5 d and PRN

4. Continue to assess daily if possible

Protocol for Braden Moisture SubscaleDeveloped by Dr. Joyce Black

M1131N 11.09

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