Braden Score for Predicting Pressure Sore Risk [link memo="See Also Norton Scale" url="//www.soapnote.org/geriatrics/norton-scale/"]
[select name="Q1" value="1 Completely Limited=1|2 Very Limited=2|3 Slightly Limited=3|4 No Impairment=4"] <-- 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 consciousness or sedation,
limited ability to feel pain over most of body surface.
2 VERY LIMITED – Responds only to painful stimuli. Cannot communicate discomfort
except by moaning or restlessness,
has a sensory impairment which limits the ability to feel pain or
discomfort over 1⁄2 of body.
3 SLIGHTLY LIMITED – Responds to verbal commands but cannot always communicate
discomfort or need to be turned,
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.
[select name="Q2" value="1 Constantly Moist=1|2 Very Moist=2|3 Occasionally Moist=3|4 Rarely Moist=4"] <-- 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 OFTEN 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.
[select name="Q3" value="1 Bedfast=1|2 Chairfast=2|3 Walks Occasionally=3|4 Walks Frequently=4"] <-- Activity (Degree of physical activity)
1 BEDFAST – Confined to bed.
2 CHAIRFAST – Ability to walk severely limited or nonexistent. 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 the room at least twice a day and inside room
at least once every 2 hours during waking hours.
[select name="Q4" value="1 Completely Immobile=1|2 Very Limited=2|3 Slightly Limited=3|4 No Limitation=4"] <-- 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
4 NO LIMITATIONS – Makes major and frequent changes in position without assistance.
[select name="Q5" value="1 Very Poor=1|2 Probably Inadequate=2|3 Adequate=3|4 Excellent=4"] <-- Nutrition (Usual food intake pattern)
1 VERY POOR – Never eats a complete meal. Rarely eats more than 1/3 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,
is NPO and/or maintained on clear liquids or IV2 for more than 5 days.
2 PROBABLY INADEQUATE – Rarely eats a complete meal and generally eats only
about 1⁄2 of any food offered. Protein intake includes only 3 servings of
meat or dairy products per day. Occasionally will take a dietary supplement
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) each day. Occasionally refuses a meal, but
will usually take a supplement if offered,
is on a tube feeding or TPN3 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.
[select name="Q6" value="1 Problem=1|2 Potential Problem=2|3 No Apparent Problem=3"] <-- 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 at all times.
Result --> [calc memo="score" value="score=(Q1)+(Q2)+(Q3)+(Q4)+(Q5)+(Q6)"] out of 23
Interpretation --> [calc memo="Risk" value="score1=(Q1)+(Q2)+(Q3)+(Q4)+(Q5)+(Q6);score1>18?'Not at high risk for pressure ulcer development':'High risk of pressure ulcer development'"]
[checkbox memo="hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).isNot('')"][html]
References: <a href="https://www.ncbi.nlm.nih.gov/pubmed/3299278" target="_blank">
Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden Scale for Predicting
Pressure Sore Risk. Nurs Res. 1987 Jul-Aug;36(4):205-10. PubMed PMID: 3299278.</a>[/html][/conditional]