Braden Scale

Question 1

1. Completely limited (sensory perception)

Answer 1

Unresponsive, limited ability to feel pain over most of the body

Question 2

2. Very limited (sensory perception)

Answer 2

Only reacts to painful stimuli, cannot communicate discomfort, sensory impairment over half the body

Question 3

3. Slightly limited (sensory perception)

Answer 3

Reacts to verbal commands, cannot always communicate discomfort, sensory impairment to one or two extremities

Question 4

4. No impairment (sensory perception)

Answer 4

Reacts to verbal commands, no sensory deficit

Question 5

1. Constantly moist (moisture)

Answer 5

Perspiration, urine, etc., Always moist

Question 6

2. Very Moist (moisture)

Answer 6

often but not always moist, linen changed at least once a shift

Question 7

Occasionally moist (moisture)

Answer 7

Extra linen changed every day

Question 8

rarely moist (moisture)

Answer 8

Usually dry

Question 9

1. bedfast (activity)

Answer 9

Never out of bed

Question 10

2. Chairfast (activity)

Answer 10

ambulation severely limited or non-existent, cannot bear own weight– assisted to chair

Question 11

walks occasionally (activity)

Answer 11

Short distances daily with or without assistance, majority of time in bed or chair

Question 12

4. Walks frequently

Answer 12

Walks outside of the room (long distances) 2x per day, inside room every 2 hrs during waking hours

Question 13

1. Completely immobile (mobility)

Answer 13

Makes no change in body or extremity position

Question 14

2. Very limited (mobility)

Answer 14

Occasional slight changes in position, Unable to make frequent/significant changes independently

Question 15

3. Slightly limited (mobility)

Answer 15

Frequent slight changes independently

Question 16

4. No limitation (mobility)

Answer 16

Major and frequent changes without assistance

Question 17

1. Very Poor (nutrition)

Answer 17

never eats a complete meal, very little protein or npo, clear liquids, IV> 5 days

Question 18

2. Probably inadequate (nutrition)

Answer 18

rarely eats a complete meal, some protein, occasionally takes dietary supplements, receives less than optimum liquid diet or tube feeding

Question 19

3. Adequate (nutrition)

Answer 19

eats over 1/2 of most meals, adequate protein, usually takes a supplement, tube feeding or TPN probably meets nutritional needs

Question 20

4. Excellent (nutrition)

Answer 20

Eats most of meal, never refuses, plenty of protein, occasionally eats snacks, does not require supplements

Question 21

1. Problem (friction and sheer)

Answer 21

moderate to max. assistance in moving, frequently slides down in bed or chair, spasticity, contractures or agitation leads to almost constant friction

Question 22

2. Potential problem (friction and sheer)

Answer 22

Moves feebly, requires min. assistance, skin probably slides against sheets, relatively good posture in chair or bed, occasional sliding

Question 23

3. No apparent problem (friction and sheer)

Answer 23

Moves independently in bed and chair, sufficient muscle strength to lift up completely during a move, good position

Question 24

Low-risk score

Answer 24

15-18

Question 25

Moderate-risk score

Answer 25

13-14

Question 26

High-risk score

Answer 26

12 or less

Question 27

moderate risk

Answer 27

regular turning schedule, enable as much activity as possible, protect heels, manage moisture, friction, and sheer, position pt 30 degree incline

Question 28

low risk

Answer 28

Regular turning schedule, Enable as much activity as possible, Protect heels, Manage moisture, friction, and sheer

Question 29

high risk

Answer 29

Regular turning schedule, Enable as much activity as possible, Protect heels, Manage moisture, friction, and sheer, Position patient at 30-degree lateral incline using wedges or pillows, Make small shifts in position frequently, Pressure redistribution surface

Question 30

higher the number _________ the risk

Answer 30

lower

Question 31

lower the number _________ the risk

Answer 31

higher