RNAO BPG Pressure Ulcers Stage I to IV - Faculty of Health ...

Assessment & Management of Stage I to IV Pressure UlcersAppendix C: Braden Scale for PredictingPressure Sore RiskPatient’s Name ___________________________Evaluator’s Name ______________________________SENSORY PERCEPTIONability to respondmeaningfully topressure-relateddiscomfortMOISTUREdegree to which skin isexposed to moistureACTIVITYdegree of physicalactivity1. Completely LimitedUnresponsive (does not moan, flinch orgrasp) to painful stimuli, due to diminishedlevel of consciousness or sedation,ORlimited ability to feel pain over mostof body.1. Constantly MoistSkin is kept moist almost constantly byperspiration, urine, etc. Dampness is detectedevery time patient is moved or turned.1. BedfastConfined to bed.2. Very LimitedResponds only to painful stimuli.Cannot communicate discomfortexcept by moaning or restlessness,ORhas a sensor impairment that limits theability to feel pain or discomfort over1/2 of body.2. Very MoistSkin is often, but not always, moist. Linenmust be changed at least once a shift.2. ChairfastAbility to walk severely limited or nonexistent.Cannot bear own weight and/ormust be assisted into chair or wheelchair.MOBILITYability to change andcontrol body positionNUTRITIONusual food intakepatternFRICTION AND SHEAR1. Completely ImmobileDoes not make even slight changes in bodyor extremity position without assistance.1. Very PoorNever eats a complete meal. Rarely eatsmore than 1/3 of any food offered. Eats2 servings or less of protein (meat or dairyproducts) per day. Takes fluids poorly.Does not take a liquid dietary supplement,ORis NPO and/or maintained on clearliquids or IVs for more than 5 days.1. ProblemRequires moderate to maximumassistance in moving. Complete liftingwithout sliding against sheets is impossible.Frequently slides down in bed or chair,requiring frequent repositioning withmaximum assistance. Spasticity,contractures or agitation lead to almostconstant friction.2. Very LimitedMakes occasional slight changes inbody or extremity position but unableto make frequent or significant changesindependently.2. Probably InadequateRarely eats a complete meal and generallyeats only about 1/2 of any food offered.Protein intake includes only 3 servingsof meat or dairy products per day.Occasionally will take a dietary supplement,ORreceives less than optimum amount ofliquid diet or tube feeding.2. Potential ProblemsMoves feebly or requires minimumassistance. During a move skinprobably slides to some extent againstsheets, chair restraints or other devices.Maintains relatively good position inchair or bed most of the time butoccasionally slides down.© Copyright Barbara Braden and Nancy Bergstrom, 1988. Reproduced with permission.80