The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 25: Prevention of Skin Breakdown26 picasTable 25-4: Braden Risk Assessment ToolSensoryPerceptionAbility to respondmeaningfully topressure-relateddiscomfort1. Completely limited:Unresponsive (does not moan,flinch, or grasp) to painfulstimuli, due to diminished levelof consciousness or sedationOR limited ability to feel painover most body surfaceSCOREMoistureDegree to whichskin is exposed tomoisture1. Constantly moist:Skin is kept moist almostconstantly by perspiration,urine, etc. Dampness isdetected every time patient ismoved or turned.ActivityDegree of physicalactivity2. Very limited:Responds only to painfulstimuli. Cannot communicatediscomfort except by moaningor restlessness OR has asensory impairment whichlimits the ability to feel pain ordiscomfort over ½ of body2. Very moist:Skin is often, but not always,moist. Linen must be changedat least once a shift.2. Chairfast:Ability to walk severely limitedor non-existent. Cannot bearown weight and/or must beassisted into chair orwheelchair.2. Very limited:Makes occasional slightchanges in body or extremityposition but unable to makefrequent or significant changesindependently.3. Slightly limited:Responds to verbal commands,but cannot always communicatediscomfort or need to beturned OR has some sensoryimpairment, which limitsability to feel pain ordiscomfort in 1 or 2extremities.3. Occasionally moist:Skin is occasionally moist,requiring an extra linen changeapproximately once a day.3. Walks occasionally:Walks occasionally during day,but for very short distances,with or without assistance.Spends majority of each shift inbed or chair.3. Slightly limited:Makes frequent, though slightchanges in body or extremityposition independently.4. No impairment:Responds to verbal commands,has no sensory deficit whichwould limit ability to feel orvoice pain or discomfort.4. Rarely moist:Skin is usually dry, linen onlyrequires changing at routineintervals.4. Walks frequently:Walks outside the room at leasttwice a day and inside room atleast once every 2 hours duringwaking hours.4. No limitations:Makes major and frequentchanges in position withoutassistance.1. Bedfast:Confined to bed.MobilityAbility to changeand control bodyposition1. Completely immobile:Does not make even slightchanges in body or extremityposition without assistance.508U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau