Braden Score for Pressure Ulcers

Addition of the selected points: Variable Points Sensory perception No impairment: responds to verbal commands, able to feel and express pain/discomfort 4 Slightly limited: responds to verbal commands but cannot always communicate discomfort or need to be turned, OR has sensory impairment limiting ability to feel pain/discomfort in 1-2 extremities 3 Very limited: responds only to pain, cannot communicate discomfort except by moaning or restlessness OR has sensory impairment limiting ability to feel pain/discomfort over half of body 2 Completely limited: unresponsive to painful stimuli due to diminished consciousness or sedation OR limited ability to feel pain over most of body 1 Moisture Rarely moist: skin usually dry, linen only requires changing at routine intervals 4 Occasionally moist: requiring extra linen change approximately once a day 3 Very moist: skin is often but not always moist; linen must be changed at least once a shift 2 Constantly moist: skin is kept moist almost constantly by perspiration, urine, etc; dampness detected every time patient is moved/turned 1 Activity Walks frequently: walks outside room ≥2x/day and inside room at least once every 2 hrs during waking hours 4 Walks occasionally: during day but for very short distances with or without assistance; spends majority of shift in bed/chair 3 Chairfast: ability to walk severely limited or non-existent; cannot bear own weight and/or must be assisted into chair/wheelchair 2 Bedfast: confined to bed 1 Mobility No limitation: makes major and frequent changes in position without assistance 4 Slightly limited: makes frequent though slight changes in body or extremity position independently 3 Very limited: makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently 2 Completely immobile: does not make even slight changes in body or extremity position without assistance 1 Nutrition Excellent: eats most of every meal; never refuses a meal; usually eats ≥4 servings of meat and dairy products; occasionally eats between meals, supplementation not required 4 Adequate: eats over half of most meals; eats 4 servings protein (meat or dairy) daily; occasionally refuses meal but will usually take supplement when offered, OR is on a tube feeding/TPN regimen which probably meets most of nutritional needs 3 Probably inadequate: rarely eats complete meal and generally eats only about ½ of any food offered; protein intake includes only 3 servings of meat or dairy products daily; occasionally will take dietary supplement, OR receives less than optimum amount of liquid diet/tube feeding 2 Very poor: never eats complete meal; rarely eats >⅓ of any food offered; eats ≤2 servings protein (meat or dairy) daily; takes fluids poorly; does not take liquid dietary supplement, OR is NPO and/or maintained on clear liquids or IV for >5 days 1 Friction & shear No apparent problem: moves in bed/chair independently, has sufficient muscle strength to lift up completely during move, maintains good position in bed/chair 3 Potential problem: moves feebly or requires minimum assistance; during a move skin probably slides to some extent against sheets, chair restraints or other devices; maintains relatively good position in chair or bed most of the time but occasionally slides down 2 Problem: requires moderate to maximum assistance in moving; complete lifting without sliding against sheets is impossible; frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance; spasticity, contractures or agitation leads to almost constant friction 1