BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK

Patient’s Name : Age: _______yrs Sex : M/ F Bed No. : UHID/ Reg No.: SCORE

Patient Diagnosis : Date of Admission : Date of Assessment : 1st 2nd 3rd

SENSORY PERCEPTION 1. Completely limited: 2.Very limited:   3.Slightly limited: 4. No impairment:

Unresponsive (does not moan or grasp)

Responds to verbal commands.
to painful stimuli due to diminished Responds only to painful Responds to verbal commands but
Ability to respond meaningfully to pressure related Has no sensory deficit which
level of consciousness or sedation ORstimuli.Cannot communicate discomfort cannot always communicate discomfort
discomfort. would limit ability to feel or
limited ability to feel pain over most of except by moaning or restlessness,or has or need to be turned,
voice pain or discomfort.
body surface a sensory impairment,which limits the
ability to feel pain or discomfort over
MOISTURE 1.Constantly moist: 2. Moist: 3.Occasionally moist: 4.Rarely moist:

Skin is kept moist almost constantly by Skin is often, but not always moist. Linen must be Skin is occasionally moist, requiring an extra Skin is usually dry; linen requires
Degree to which skin is exposed to moisture
perspiration, Urine ctc changed once a shift. linen change once a day changing only at routine intervals

ACTIVITY 1. Bedfast: 2.Chairfast: 3. Walks occasionally: 4.Walks frequently:

Ability to walk severely limited or non-existent. Walks occasionally during day but for very Walks outside the room twice a day
Degree of physical activity Confined to bed.
Cannot bear own weight short distances and inside room at every 2 hours

MOBILITY 1.Completely Immobile: 2. Very limited: 3. Slightly limited 4.No Limitation

Makes occasional slight changes in body or

Does not make even slight changes in body or Makes frequent though slight changes in body Makes Major& frequent changes in
Ability to change and control body position extremity position but unable to make frequent
extremity position without assistance extremity position independently position without assistance
or significant changes

NUTRITION 1. Very Poor 2.Probably Inadequate 3. Adequate: 4.Excellent:

Eats most of every meal. Never

Rarely eats more than ⅓ of any food
offered. Eats 2 servings or less of protein per
Usual food intake pattern
day.Takes fluids poorly. Does not take a
NPO Nothing by mouth
liquid dietary supplement, or is NPO or on
clear liquids oron IV fliuds
Rarely eats a complete meal Protein intake
includes only 3 servings . of meat or dairy
products per day. Occasionally will take a dietary
suppliment orrecieves less than optimum amount
of liquid diet or tube feeding
Eats over half of most meals. Eats a total of 4
refuses a meal. Usually eats a total of
servings of protein each day. Occasionally will
4 or more servings of meat and dairy
refuse a meal,but will usually take a
products. Occasionally eats between
suppliment of offered, or Is on a tube feeding
meals. Does not require
or TPN regimen
supplementation

FRICTION & SHEAR 1. Problem: 2. Potential problem: 3.No Apparent Problem:

Requires moderate to maximum assistance in

Moves freely or requires minimum assistance.
moving. Complete lifting without sliding
During a move, skin probably slides to some
against sheets is impossible. Frequent slides
extent against sheets, chair, restraints, or other
down in bed orchair, requiring frequent
devices. Maintains elatively good position in chair
repositioning with maximum assistance.
or bed most of the time but occasionally slides
Spasticity, contractures, or agitation leads to
down.
almost constant friction.

Does patient have pressure ulcer? Yes / No Yes / No Yes / No

Moves in bed and in chair independently and
Site has sufficientmuscle strength to lift up
TOTAL SCORE
Size / Grade completely during move. Maintains good
position in bed or chair . at all times
Action taken ( dressing/matress)
Grade - I redness of skin & Skin peeling

Grade- II Ulcers involving subcutaneous tissue

Grade - III ulcer involving Muscle

Ulcers involving subcutaneous tissues, muscles,

Grade- IV
tendons & bone

6-8 : HIGH RISK, 9-10 : MEDIUM HIGH RISK, 11-12 : MEDIUM RISK,1316:LOW RISK

*NOTE: Patients with a total score of 16 or less are considered to be at risk of developing pressure ulcers.

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