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

Nursing Best Practice GuidelineNote: Individuals with a score of 18 or less are considered to be at risk of developing pressure ulcers.At risk – 15 to 18; Moderate Risk – 13 to 14; High Risk – 10 to 12; Very High Risk – 9 or below.Braden, 2001Date of Assessment3. Slightly LimitedResponds to verbal commands, butcannot always communicatediscomfort or the need to be turned,ORhas some sensory impairment whichlimits ability to feel pain or discomfortin 1 or 2 extremities.4. No ImpairmentResponds to verbal commands. Has nosensory deficit which would limitability to feel or voice pain or discomfort.3. Occasionally MoistSkin is occasionally moist, requiringan extra linen change approximatelyonce a day.4. Rarely MoistSkin is usually dry, linen only requireschanging at routine intervals.3. Walks OccasionallyWalks occasionally during day, but forvery short distances with or withoutassistance. Spends majority of eachshift in bed or chair.4. Walks FrequentlyWalks outside the room at least twice aday and inside room at least every 2hours during waking hours.3. Slightly LimitedMakes frequent though slight changes inbody or extremity position independently.4. No LimitationMakes major and frequent changes inposition without assistance.3. AdequateEats over half of most meals. Eats atotal of 4 servings of protein (meat ordairy products) each day. Occasionallywill refuse a meal, but will usually takea supplement if offered,ORis on a tube feeding or TPN regimen,which meets most of nutritional needs.4. ExcellentEats most of every meal. Never refusesa meal. Usually eats a total of 4 or moreservings of meat and dairy products.Occasionally eats between meals. Doesnot require supplementation.3. No Apparent ProblemMoves in bed and in chairindependently and has sufficientmuscle strength to lift up completelyduring move. Maintains good positionin bed or chair.TOTAL SCORE81