Page 27 - CLINICAL PRACTICE II

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Appendix 1

BRADEN SCALE – For Predicting Pressure Sore Risk
Use the form only for the approved purpose. Any use of the form in publications (other
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SEVERE RISK: Total score 9 HIGH RISK: Total score 10-12
MODERATE RISK: Total score 13-14 MILD RISK: Total score 15-18 DATE OF ASSESS:

RISK SCORE/
FACTOR 1 2 DESCRIPTION 3 4

SENSORY 1. COMPLETELY 2. VERY LIMITED – 3. SLIGHTLY 4. NO IMPAIRMENT
PERCEPTION LIMITED – Responds only to LIMITED – – Responds to
Ability to Unresponsive painful verbal
respond (does not moan, stimuli. Cannot Responds to commands. Has
meaningfully flinch, or communicate verbal commands no sensory deficit
to grasp) to painful discomfort except by but cannot always which would limit
pressure- stimuli, moaning discomfort or ability to feel or
related due to diminished or restlessness, OR has need to be turned, OR voice pain or
discomfort level of a discomfort
consciousness or limits the ability to feel has some sensory
sedation, impairment which limits
pain ability to feel pain or
OR limited ability or discomfort over ½ of discomfort in 1 or
to feel pain over body. 2 extremities.
most of body
surface.

MOISTURE 1. CONSTANTLY 2. OFTEN MOIST – 3. 4. RARELY MOIST
Degree to MOIST– Skin is kept Skin is often but not OCCASIONAL – Skin is usually
which moist almost always moist. Linen LY MOIST – dry; linen only
skin is constantly by must be changed at Skin is requires changing
exposed to perspiration, urine, least once a shift. occasionally at routine intervals.
moisture etc. moist, requiring
Dampness is an extra linen
detected change
every time patient is approximately once
moved or turned. a day.

ACTIVITY 1. BEDFAST – 2. CHAIRFAST – 3. WALKS 4. WALKS
Degree of Confined to bed. Ability to walk severely OCCASIONALLY – FREQUENTLY–
physical limited or non-existent. Walks occasionally Walks outside the
activity Cannot bear own during day, but room
weight and/or must be for very short at least twice a day
assisted into chair or distances, with or and

wheelchair. without assistance. inside room at least
Spends majority of once every 2 hours
during waking hours.
each shift in bed or
chair.

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