Tool and Resource Evaluation Template - Department of Health

Tool and Resource Evaluation Template 

Adapted by NARI from an evaluation template created by Melbourne Health. 

Some questions may not be applicable to every tool and resource. 

Name and purpose 

Target audience 

(the tool is to be 

used by) 

Target 

population/setting 

(to be used on/in) 

Name of the resource: Braden Scale 

Author(s) of the resource: B. Braden and N. Bergstrom. 

Please state why the resource was developed and what gap it proposes to fill: 

Composed of six subscales: mobility, activity, sensory perception, skin moisture, nutritional status, 

and friction. Each subscale has its own operational definitions which are ranked from 1 (least 

favourable) to 3 or 4 (most favourable). Scores range from 6 to 23. The cut off point at which a 

patient is considered ‘at risk’ is 16 points or less. 

Identification of individual risk factors is helpful in directing care. 

Please check all that apply: 

Health service users 

Carers 

Medical staff Nursing staff Any member of an interdisciplinary team 

Medical specialist, please specify: 

Specific allied health staff, please specify: 

Other, please specify: 

Is the resource targeted for a specific setting? Please check all that apply: 

Emergency Department Inpatient acute Inpatient subacute Ambulatory 


For which particular health service users would you use this resource (e.g. a person with 

suspected cognitive impairment)? 

All in-patients in acute and subacute settings, or residential care settings. 

Structure of tool Website Education package Video 

Pamphlet Assessment tool Screening tool 

Methodology Resource guide Awareness raising resource (posters etc.) 


Please state the size of the resource (e.g. number of pages, minutes to read): 

1 page, usually printed in A4 

Takes less than one minute to complete once the patient is assessed. 

Availability and 

cost of tool 

Applicability to 

rural settings and 

culturally and 

linguistically 

diverse 

populations 

Person-centred 

principles 

Training 

Is the resource readily available? Yes No Unknown Not applicable 

Is there a cost for the resource? Yes No Unknown Not applicable 

Please state how to get the resource: 

This scale is provided below: 

BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK 

The Braden Scale is also readily available via the internet and is recommended by the Australian 

Wound Management Association. 

Is the resource suitable for use in rural health services (e.g. the necessary staff are usually 

available in rural settings)? Yes No Unknown Not applicable 

Is the resource available in different languages? 

Yes No Unknown Not applicable for use by staff 

Is the content appropriate for different cultural groups? 

Yes No Unknown Not applicable 

Does the resource adhere to/promote person-centred health care? 


Is additional training necessary to use the resource?

equirements Yes No Unknown Not applicable 

Administration 

details 

If applicable, please state how extensive any training is, and what resources are required: 

How long does the resource take to use? 0-5 mins 5-15 mins 15-25mins 25mins + 

Can the resource be used as a standalone, or must it be used in conjunction with other 

tools, resources, and procedures? 

Standalone 

Must be used with other resources, please specify: 

Can be used with other tools, please specify: 

Data collection and 

analysis 

Are additional resources required to collect and analyse data from the resource? 


If applicable, please state any special resources required (e.g. computer software): 

Sensitivity and 

specificity 

Sensitivity is the proportion of people that will be correctly identified by the tool. 

Specificity is the probability that an individual who does not have the condition being tested 

for will be correctly identified as negative. 

Has the sensitivity and specificity of the resource been reported? 


If applicable, please state what has been reported: 

Initial studies reported 83 - 100% sensitivity and 64-90% specificity. In subsequent studies, 

sensitivity has ranged from 22 – 89% and specificity has ranged from 56 – 100% (Defloor & 

Grypdonck, 2004). 

Face Validity 

Reliability 

Does the resource appear to meet the intended purpose? 


Reliability is the extent to which the tool’s measurements remain consistent over repeated 

tests of the same subject under identical conditions. Inter-rater reliability measures 

whether independent assessors will give similar scores under similar conditions. 

Has the reliability of the resource been reported? 


If applicable, please state what has been reported: 

Percentage agreement of up to 88% was achieved and correlational measures of reliability were 

excellent when used by a registered nurse (r = 0.99). However, Raycroft-Malone (2000) argues 

that the reliability has not been properly assessed. Bergstrom and Braden recommended that that 

registered nurses use the tool. Scores less reliable when the tool was used by less qualified staff. 

Strengths 

What are the strengths of the resource? Is the resource easy to understand and use? Are 

instructions provided on how to use the resource? Is the resource visually well presented 

(images, colour, font type/ size)? Does the resource use older friendly terminology (where 

relevant), avoiding jargon? 

Please state any other known strengths, using dot points: 

• User friendly and quick. 

• Reliable when used by nursing staff. 

• In common usage in Australia and USA. 

• Validity compares well with Norton and Waterlow scales. 

Limitations 

What are the limitations of the tool/resource? Is the tool/resource difficult to understand 

and use? Are instructions provided on how to use the tool/resource? Is the tool/resource 

poorly presented (images, colour, font type/ size)? Does the tool/resource use difficult to 

understand jargon? 

Please state any other known limitations, using dot points: 

• Reliability is reduced when not used by nursing staff. 

• Experienced nurses should conduct the risk assessment (Papanikolaou et al., 2007). 

• Critical cut-off score is disputable (Papanikolaou et al., 2007). 

References and 

further reading 

Supporting references and associated reading. 

1. Australian Wound Management Association Clinical Practice Guidelines for the prediction

and prevention of pressure ulcers. Available at: 

http://www.awma.com.au/publications/2007/cpgpppu_v_full.pdf 

2. Health Services Technology Assessment Test - National Library of Medicine. 

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.4409 

3. Braden B & Bergstrom N. A conceptual scheme for the study of etiology of pressure 

sores. Rehabilitation Nursing. 1987;12:8-16. 

4. Defloor T & Grypdonck M. Validation of pressure ulcer risk assessment scales: a critique. 

Journal of Advanced Nursing. 2004;48:613-621. 

5. Papanikolaou P, Lyne P & Anthony D. Risk assessment scales for pressure ulcers: A 

methodological review. International Journal of Nursing Studies, 2007;44:285-296. 

6. Raycroft-Malone J. Pressure ulcer risk assessment and prevention. Technical reporting. 

2000 RCN Publishing, London.

BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK 

Patient=s Name _____________________________________ Evaluator=s Name________________________________ Date of Assessment 

SENSORY PERCEPTION 

ability to respond meaningfully 

to pressure-related 

discomfort 

1. Completely Limited 

Unresponsive (does not moan, 

flinch, or grasp) to painful 

stimuli, due to diminished level of 

con-sciousness or sedation. 

OR 

limited ability to feel 

pain over most of body 

2. Very Limited 

Responds only to painful 

stimuli. Cannot communicate 

discomfort except by moaning 

or restlessness 

OR 

has a sensory impairment which 

limits the ability to feel pain or 

discomfort over 2 of body. 

3. Slightly Limited 

Responds to verbal commands, 

but cannot always 

communicate discomfort or the 

need to be turned. 

OR 

has some sensory impairment 

which limits ability to feel pain 

or discomfort in 1 or 2 extremities. 

4. No Impairment 

Responds to verbal 

commands. Has no 

sensory deficit which would 

limit ability to feel or voice 

pain or discomfort.. 

MOISTURE 

degree to which skin is 

exposed to moisture 

1. Constantly Moist 

Skin is kept moist almost 

constantly by perspiration, urine, 

etc. Dampness is detected 

every time patient is moved or 

turned. 

2. Very Moist 

Skin is often, but not always moist. 

Linen must be changed at least 

once a shift. 

3. Occasionally Moist: 

Skin is occasionally moist, requiring 

an extra linen change approximately 

once a day. 

4. Rarely Moist 

Skin is usually dry, linen 

only requires changing at 

routine intervals. 

ACTIVITY 

degree of physical activity 

1. Bedfast 

Confined to bed. 

2. Chairfast 

Ability to walk severely limited or 

non-existent. Cannot bear own 

weight and/or must be assisted into 

chair or wheelchair. 

3. Walks Occasionally 

Walks occasionally during day, but 

for very short distances, with or 

without assistance. Spends 

majority of each shift in bed or chair 

4. Walks Frequently 

Walks outside room at least 

twice a day and inside room 

at least once every two 

hours during waking hours 

MOBILITY 

ability to change and control 

body position 

1. Completely Immobile 

Does not make even slight 

changes in body or extremity 

position without assistance 

2. Very Limited 

Makes occasional slight changes in 

body or extremity position but 

unable to make frequent or 

significant changes independently. 

3. Slightly Limited 

Makes frequent though slight 

changes in body or extremity 

position independently. 

4. No Limitation 

Makes major and frequent 

changes in position without 

assistance. 

NUTRITION 

usual food intake pattern 

1. Very Poor 

Never eats a complete meal. 

Rarely eats more than a of any 

food offered. Eats 2 servings or 

less of protein (meat or dairy 

products) per day. Takes fluids 

poorly. Does not take a liquid 

dietary supplement 

OR 

is NPO and/or maintained on 

clear liquids or IV=s for more 

than 5 days. 

2. Probably Inadequate 

Rarely eats a complete meal and 

generally eats only about 2 of any 

food offered. Protein intake 

includes only 3 servings of meat or 

dairy products per day. 

Occasionally will take a dietary 

supplement. 

OR 

receives less than optimum amount 

of liquid diet or tube feeding 

3. Adequate 

Eats over half of most meals. Eats 

a total of 4 servings of protein 

(meat, dairy products per day. 

Occasionally will refuse a meal, but 

will usually take a supplement when 

offered 

OR 

is on a tube feeding or TPN 

regimen which probably meets 

most of nutritional needs 

4. Excellent 

Eats most of every meal. 

Never refuses a meal. 

Usually eats a total of 4 or 

more servings of meat and 

dairy products. 

Occasionally eats between 

meals. Does not require 

supplementation. 

FRICTION & SHEAR 

1. 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 

2. 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. 

3. No Apparent Problem 

Moves in bed and in chair 

independently and has sufficient 

muscle strength to lift up 

completely during move. Maintains 

good position in bed or chair. 

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

Tool and Resource Evaluation Template - Department of Health

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