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!