Responds to verbal command

No sensory deficit which would limit

ability to feel of voice pain or discomfort

Responds to verbal commands

Cannot always communicate

discomfort or need to be turned

Sensory impairment that limits ability to feel pain in 1 or 2

extremities

Responds only to painful stimuli

Ability to communicate

discomfort limited to moaning and/or

restlessness

Sensory impairment that limits ability to feel pain over ½ of

body

Unresponsive to painful stimuli due to

diminished consciousness or

sedation

Does not moan, flinch or grasp

Limited ability to feel pain over most of

body surface

Braden Scale Sensory Subsection

Sensory

4

No Impairment

3

Slightly Limited

2

Very Limited

1

Completely Limited

Assess Patients Ability To Respond Meaningfully To Pressure Related Discomfort!

Hig

h R

isk

Low

Ris

k

1. Ensure heels are off of bed surfaces

2. Ensure patient is not lying on objects

and/or lines, tubes, and drains

3. Turn every 2 hours with 30 degree tilt

4. Select and apply appropriate surfaces

5. Apply bordered foam to the appropriate

risk areas

High Risk Interventions

Rarely Moist Skin is usually dry

Occasionally Moist

Occasional perspiration,

drainage, and/or incontinence

Requires one linen change per day

Often Moist

Frequent perspiration,

drainage, and/or incontinence

Requires one linen change per shift

Constantly Moist

Constant perspiration,

drainage, and/or incontinence.

Requires two or more linen changes

per shift

Requires change at routine intervals

Braden Scale Moisture Subsection

Moisture

4

EXCELLENT

4

EXCELLENT

3

ADEQUATE

3

ADEQUATE

2

PROBABLY INADEQUATE

1

VERY POOR

Identify Moisture Risk And Keep The Patient Clean And Dry!

Hig

h R

isk

Low

Ris

k

1. Apply skin protectant barriers

2. Offer toileting assistance every 2 hours

3. Consider low air loss surface

4. Consider incontinence management

devices as appropriate

5. Only use briefs while ambulating

High Risk Interventions

Braden Scale Activity Subsection

Hig

h R

isk

Low

Ris

k

High Risk Interventions

1. Identify the patient’s activity level, level

of assistance and appropriate DME

2. If chairfast or bedbound apply pressure

relief surfaces to alleviate pressure

3. Turn every 2 hours with 30 degree tilt

Walks frequently in the room

Walks outside of the room at least twice a

day

Walks occasionally in room

Walks occasionally in very short distances

Ability to walk severely limited or

nonexistent

Cannot bear own weight and/or must

be assisted into chair or wheelchair

Minimum x 1 assist for all out of bed

activities

Confined to bed

Identify The Patients Degree Of Physical Activity!

Activity

4

WALKS FREQUENLY

3

WALKS OCCASIONALLY

2

CHAIRFAST

1

BEDBOUND

Makes major and frequent changes in

position

Does not need assistance to change

position in bed or while in chair

Makes frequent though slight changes

in position

Minimal or no assistance needed with positioning

Makes occasional or slight body and/or extremity position

Needs assistance with repositioning minimum x1 assist

Does not make even slight changes in body or extremity position

Total care- minimum x2 assist

Braden Scale Mobility Subsection

Mobility

4

NO LIMITATION

3

SLIGHTLY LIMITED

2

VERY LIMITED

1

COMPLETELY IMMOBILE

Hig

h R

isk

Low

Ris

k

1. Assist to chair position for all meals; at

least twice daily

2. Apply appropriate pressure relief surfaces

3. Turn every 2 hours with 30 degree tilt

4. Do not use donuts or rings

5. Shift weight every 15 minutes while up in

chair

High Risk Interventions

Identify The Patients Ability To Change And Control Body Positions!

Eats most of all meals & never refuses food

Does not require or need supplements

Eats over half of most meals

May refuse a meal but will take a supplement

On Tube Feeding or TPN

Generally eats ½ of food offered

Occasionally may take a supplement

Receives less than desired goal for tube

feeding

Rarely eats at least ½ of food offered

Does not take supplements

TPN, clear liquids or NPO for greater than

5 days

Braden Scale Nutrition Subsection

Nutrition

4

EXCELLENT

3

ADEQUATE

2

PROBABLY INADEQUATE

1

VERY POOR

Identify The Patients Usual Food Intake Pattern!

Hig

h R

isk

Low

Ris

k

1. Assess nutritional intake each shift

2. Obtain dietary consult order

3. Offer fluids with each encounter

4. Promote dietary supplements

5. Monitor weight weekly, as ordered or

per unit standard of care

High Risk Interventions

Mobility independent with good strength

and positioning

Does not require assistance with

positioning

Requires some (25%) help, moves feebly

While moving, skin slides on sheets,

chairs, etc.

Occasionally slides in bed or chair

Requires a lot of help (50–75%)

Frequently slides in chair, frequently requires assist to

reposition

Spasticity, contractures,

agitation present

Braden Scale Friction & Shear Subsection

Friction/Shear

3

NO APPARENT PROBLEM

2

POTENTIAL PROBLEM

1

PROBLEM

Hig

h R

isk

Low

Ris

k

1. Utilize positioning and offloading

regularly

2. Use appropriate surfaces to reduce and

relieve pressure

3. Apply barriers and dressings to reduce

shear and friction

4. Consider PT consult to promote mobility

High Risk Interventions

Identify The Patients Level Of Friction And Shear!