braden scale.pdf braden scale pressure sore

braden scale

1. BRADEN SCALE

2. Introduction
Developed1984byBradenand
Bergstrom
Thescaleconsistsofsixsubscalesand
thetotalscoresrangefrom6-23.
AlowerBradenscoreindicateshigher
levelsofriskforpressureulcer
development.

3. Six Parameters
1.Sensory perception
2.Moisture
3.Activity
4.Mobility
5.Nutrition
6.Friction and shear

4. Instructions for Scoring
Completetheformbyscoringeachitemfrom1-
4(1forlowleveloffunctioningand4forhighest
leveloffunctioning)forthefirstfiveriskfactors
and1-3forthelastriskfactor.
Thelowerthescore,thegreatertherisk.
19-23=Norisk
15-18=MildRisk
13-14=ModerateRisk
10-12=HighRisk
9orless=VeryHighRisk

5. Example of Braden Scale
Sensory
Percepti
on
Moisture ActivityMobilityNutrition
Friction
and
Shear
No
Impair
ment
4
Rarely
Moist
4
Walks
Frequen
tly
4
No
Limitati
ons
4
Excellen
t
4
Slightly
Limited
3
Occasion
ally
Moist
3
Walks
Occasio
naly
3
Slightly
Limited
3
Adequat
e
3
No
Appare
nt
Proble
m
3
Very
Limited
2
Very
Moist
2
Chair
bound
2
Very
Limited
2
Probabl
y
Inadequ
ate
2
Potenti
al
Proble
m
2
Compl
etely
Limited
1
Constant
ly Moist
1
Bedbou
nd
1
Comple
tely
Immobi
le
1
Very
Poor
1
Proble
m
1

6. 1. Sensory Perception
Ability to
respond
meaningfu
lly to
pressure-
related
discomfort
1.Completely
Limited
Unresponsive
(does not
respond to
painful stimuli)
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
3.Slightly
Limited
Responds to
verbal
commands, but
cannot always
communicate
discomfort
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 pain or
discomfort.

7. 2. Moisture
Degree to
which skin
is exposed
to
moisture
1.Constantly
Moist
Skin is kept
moist
almost
constantly
by
perspiration,
urine, etc.
2.Very
Moist
Skin is
moist
often, but
not
always.
Linen
change
approxim
ately
each 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.

8. 3. Activity
Degree
of
physical
activity
1.Bedfast
Confined
to bed.
2. Chairfast
Ability to walk
very limited or
non-existent.
Cannot bear
own weight
and must be
assisted into
chair or
wheelchair.
3.Walks
Occasionally
Walks
occasionally
during day, but
for very short
distances.
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.

9. 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
changes
independently
3.Slightly
Limited
Makes
frequent
slight
changes in
body or
extremity
position
independen
tly.
4.No
Limitations
Makes major
and frequent
changes in
position
without
assistance

10. 5. Nutrition
Usual
food
intake
pattern
1.Very Poor
Never eats a
complete meal.
Eats 2 servings or
less of protein per
day.
Takes fluids poorly.
Does not take a
dietary
supplement.
Receivesclear
liquids or IVs for
more than 5 days.
2.Probably
Inadequate
Rarely eats a
complete meal
Eats only 3 servings
of protein per day.
Occasionally 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
each day.
Usually take a
supplement if
offered.
Receivestube
feeding or TPN
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 protein per
day.
Does not
require
supplementat
ion.

11. 6. Friction and Shear
Friction
and
Shear
1. Problem
Requires
moderate to
maximum
assistance in
moving.
Complete
lifting without
sliding against
sheets is
impossible.
2. Potential Problem
Movement requires
minimum assistance.
During a move, skin
probably slides to some
extent against sheet.
Maintains 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.

12. NORTAN SCALE

13. INTRODUTION
TheNortonScalewasdevelopedinthe1960s
andiswidelyusedtoassesstheriskfor
pressureulcerinadultpatients.
ThefivesubscalescoresoftheNortonScaleare
addedtogetherforatotalscorethatranges
from5-20.
AlowerNortonscoreindicateshigherlevelsof
riskforpressureulcerdevelopment.
Generally,ascoreof14orlessindicatesat-risk
status.

14. Five Parameters
1.Physicalcondition
2.Mentalcondition
3.Activity
4.Mobility
5.Incontinence

15. Instructions for Scoring
Completetheformbyscoringeachitemfrom
1-4.
Thelowerthescore,thegreatertherisk.
>18=Lowrisk
14-18=MediumRisk
10-14=HighRisk
<10=VeryHighRisk

16. Example of NortanScale
Physical
Condition
Mental
Condition
Activity MobilityIncontinence
Good 1 Alert 1Ambulant 1 Full 1 None 1
Fair2Apathetic 2
Walks
with help
2
Slightly
impaired
2Occasional 2
Poor3Confused 3
Chair
bound
3
Very
limited
3
Usually
urinary
3
Very
Bad
4Stuporous4Bedfast 4Immobile 4
Urinary and
Fecal
4