Braden Scale Form – Fill Out and Use

Patient=s Name _____________________________________

Evaluator=s Name________________________________

Date of Assessment

SENSORY PERCEPTION

1. Completely Limited

2. Very Limited

3. Slightly Limited

4. No Impairment

Unresponsive (does not moan,

Responds only to painful

Responds to verbal com-

Responds to verbal

ability to respond meaning-

flinch, or grasp) to painful

stimuli. Cannot communicate

mands, but cannot always

commands. Has no

fully to pressure-related

stimuli, due to diminished level of

discomfort except by moaning

communicate discomfort or the

sensory deficit which would

discomfort

con-sciousness or sedation.

or restlessness

need to be turned.

limit ability to feel or voice

OR

OR

OR

pain or discomfort..

limited ability to feel

has a sensory impairment which

has some sensory impairment

pain over most of body

limits the ability to feel pain or

which limits ability to feel pain

discomfort over 2 of body.

or discomfort in 1 or 2 extremities.

MOISTURE

1. Constantly Moist

2. Very Moist

3. Occasionally Moist:

4. Rarely Moist

Skin is kept moist almost

Skin is often, but not always moist.

Skin is occasionally moist, requiring

Skin is usually dry, linen

degree to which skin is

constantly by perspiration, urine,

Linen must be changed at least

an extra linen change approximately

only requires changing at

exposed to moisture

etc. Dampness is detected

once a shift.

once a day.

routine intervals.

every time patient is moved or

turned.

ACTIVITY

1. Bedfast

2. Chairfast

3. Walks Occasionally

4. Walks Frequently

Confined to bed.

Ability to walk severely limited or

Walks occasionally during day, but

Walks outside room at least

degree of physical activity

non-existent. Cannot bear own

for very short distances, with or

twice a day and inside room

weight and/or must be assisted into

without assistance. Spends

at least once every two

chair or wheelchair.

majority of each shift in bed or chair

hours during waking hours

MOBILITY

1. Completely Immobile

2. Very Limited

3. Slightly Limited

4. No Limitation

Does not make even slight

Makes occasional slight changes in

Makes frequent though slight

Makes major and frequent

ability to change and control

changes in body or extremity

body or extremity position but

changes in body or extremity

changes in position without

body position

position without assistance

unable to make frequent or

position independently.

assistance.

significant changes independently.

NUTRITION

1. Very Poor

2. Probably Inadequate

3. Adequate

4. Excellent

Never eats a complete meal.

Rarely eats a complete meal and

Eats over half of most meals. Eats

Eats most of every meal.

usual food intake pattern

Rarely eats more than a of any

generally eats only about 2 of any

a total of 4 servings of protein

Never refuses a meal.

food offered. Eats 2 servings or

food offered. Protein intake

(meat, dairy products per day.

Usually eats a total of 4 or

less of protein (meat or dairy

includes only 3 servings of meat or

Occasionally will refuse a meal, but

more servings of meat and

products) per day. Takes fluids

dairy products per day.

will usually take a supplement when

dairy products.

poorly. Does not take a liquid

Occasionally will take a dietary

offered

Occasionally eats between

dietary supplement

supplement.

OR

meals. Does not require

OR

OR

is on a tube feeding or TPN

supplementation.

is NPO and/or maintained on

receives less than optimum amount

regimen which probably meets

clear liquids or IV=s for more

of liquid diet or tube feeding

most of nutritional needs

than 5 days.

FRICTION & SHEAR

1. Problem

2. Potential Problem

3. No Apparent Problem

Requires moderate to maximum

Moves feebly or requires minimum

Moves in bed and in chair

assistance in moving. Complete

assistance. During a move skin

independently and has sufficient

lifting without sliding against

probably slides to some extent

muscle strength to lift up

sheets is impossible. Frequently

against sheets, chair, restraints or

completely during move. Maintains

slides down in bed or chair,

other devices. Maintains relatively

good position in bed or chair.

requiring frequent repositioning

good position in chair or bed most

with maximum assistance.

of the time but occasionally slides

Spasticity, contractures or

down.

agitation leads to almost

constant friction

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

Total Score