Braden-Scale Chart Template printable pdf download

Braden-Scale

1 point

2 points

3 points

4 points

Sensory perception

Completely limited

Very limited

Slightly limited

No impairment

Ability respond meaningfully

Unresponsive (does not

Responds only to painful

Responds to verbal

to pressure-related

moan, flinch or grasp) to

stimuli. Cannot

commands but cannot

commands

discomfort

painful stimuli, due to

communicate discomfort

always communicate

diminished level of

except by moaning or

discomfort or need to be

Has no sensory deficit

consciousness or sedation

restlessness

turned

which would limit ability to

feel or voice pain or

Limited ability to feel pain

Has a sensory impairment

Has some sensory

discomfort

over most of body surface

which limits the ability to

impairment which limits

feel pain or discomfort

ability to feel pain or

over ½ of body

discomfort in 1 or 2

extremities

Moisture

Constantly moist

Moist

Occasionally moist

Rarely moist

Degree to which skin is

Skin is kept moist almost

Skin is often but not

Skin is occasionally moist,

Skin is usually dry;

exposed to moisture

constantly by perspiration,

always moist.

requiring an extra linen

Linen requires changing

urine, etc.

Linen must be changed at

change approximately once

only at routine intervals

Dampness is detected

least once a shift

a day

every time patient is

moved or turned

Activity

Bedfast

Chairfast

Walks occasionally

Walks frequently

Degree of physical activity

Confined to bed

Ability to walk severly

Walks occoaionally during

Walks outside the room at

limited or non-existent

day but for very short

least twice a day and inside

Cannot bear own weight

distances, with or without

room at least once very 2

and / or must be assisted

assistance

hours during waking hours

into chair or wheel chair

Spends majority of each

shift in bed or chair

Mobility

Completely immobile

Very limited

Slightly limited

No limitations

Ability to change and control

Does not make even slight

Makes occasional slight

Makes frequent though

Makes major and frequent

body position

changes in body or

slight changes in body or

changes in position without

extremity position without

extremity position

assistance

Unable to make frequent

independently

or significant changes

independently

Nutrition

Very poor

Probably inadequate

Adequate

Excellent

Usual food intake pattern

Never eats a complete

Rarely eats a complete

Eats over half of most

Eats most of every meal,

meal. Rarely eats more

meal and generally eats

meals

never refuses a meal

than 1/3 of any food

only about ½ of any food

Eats a total of 4 servings of

Usually eats a total of 4 or

offered

protein (meat, dairy

more servings of meat and

Eats 2 servings or less of

Protein intake includes

products) each day

dairy products

protein (meat or dairy

only 3 servings of meat or

Occasionally will refuse a

Occasionally eats between

products) per day

dairy products per day

meal, but will usually take a

meals

Takes fluids poorly

Occasionally will take a

supplement if offered

Does not require

Does not take a liquid

dietary supplement

supplementation

dietary supplement

Is on a tube feeding or TPN

Receives less than

[3] regimen, which

Is NPO [1]

optimum amount of liquid

probably meets most of

AND / OR

diet or tube feeding

nutritional need

Maintained on clear liquids

OR IV [2]

For more than 5 days

Friction and shear

Problem

Potential problem

No apparent problem

Requires moderate to

Moves feebly or requires

Moves in bed and in chair

maximum assistance in

minimum assistance

independently

moving

During a move skin

Has sufficient muscle

Complete lifting without

probably slides to some

strength to lift up

sliding against sheets is

extent against sheets,

completely during move

impossible

chair, restraints, or other

Maintains food position in

Frequently slides down in

devices

bed or chair at all times

bed or chair, requiring

Maintains relatively good

frequent repositioning with

position in chair or bed

maximum assistance

most of the time

Spasticity, contractures

Occasionally slides down

OR-

Agitation leads to almost

constant friction

Please assign the condition of the patient to one of the 4 possible descriptions stated in the scale. The

single points shall be added up. At a sum of 18 or less, an increased risk for pressure ulcers is

existing. The less points reached, the higher the risk. In order to avoid the development of pressure ulcers

the necessary caring measurements shall be planned, initiated and executed.

Risk for pressure ulcers

low (23 - 20 points)

high (15 - 11 points)

Total score:

medium (19 - 16 points)

very high (10 - 6 points)

acc. to Braden-Scale:

Braden-Scale Chart Template

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