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    Patent Pending

    Braden Score for Pressure Ulcers

    Identifies patients at risk for pressure ulcers.
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    Select the closest description:
    No impairment: responds to verbal commands, able to feel and express pain/discomfort
    +4
    Slightly limited: responds to verbal commands but cannot always communicate discomfort or need to be turned, OR has sensory impairment limiting ability to feel pain/discomfort in 1-2 extremities
    +3
    Very limited: responds only to pain, cannot communicate discomfort except by moaning or restlessness, OR has sensory impairment limiting ability to feel pain/discomfort over half of body
    +2
    Completely limited: unresponsive to painful stimuli due to diminished consciousness or sedation, OR limited ability to feel pain over most of body
    +1
    Rarely moist: skin usually dry, linen only requires changing at routine intervals
    +4
    Occasionally moist: requiring extra linen change approximately once a day
    +3
    Very moist: skin is often but not always moist; linen must be changed at least once a shift
    +2
    Constantly moist: skin is kept moist almost constantly by perspiration, urine, etc; dampness detected every time patient is moved/turned
    +1
    Walks frequently: walks outside room ≥2x/day and inside room at least once every 2 hrs during waking hours
    +4
    Walks occasionally: during day but for very short distances with or without assistance; spends majority of shift in bed/chair
    +3
    Chairfast: ability to walk severely limited or non-existent; cannot bear own weight and/or must be assisted into chair/wheelchair
    +2
    Bedfast: confined to bed
    +1
    No limitation: makes major and frequent changes in position without assistance
    +4
    Slightly limited: makes frequent though slight changes in body or extremity position independently
    +3
    Very limited: makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently
    +2
    Completely immobile: does not make even slight changes in body or extremity position without assistance
    +1
    Excellent: eats most of every meal; never refuses a meal; usually eats ≥4 servings of meat and dairy products; occasionally eats between meals; supplementation not required
    +4
    Adequate: eats over half of most meals; eats 4 servings protein (meat or dairy) daily; occasionally refuses meal but will usually take supplement when offered; or is on a tube feeding/TPN regimen which probably meets most of nutritional needs
    +3
    Probably inadequate: rarely eats complete meal and generally eats only about ½ of any food offered; protein intake includes only 3 servings of meat or dairy products daily; occasionally will take dietary supplement; or receives less than optimum amount of liquid diet/tube feeding
    +2
    Very poor: never eats complete meal; rarely eats >⅓ of any food offered; eats ≤2 servings protein (meat or dairy) daily; takes fluids poorly; does not take liquid dietary supplement; or is NPO and/or maintained on clear liquids or IV for >5 days
    +1
    No apparent problem: moves in bed/chair independently, has sufficient muscle strength to lift up completely during move, maintains good position in bed/chair
    +3
    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
    +2
    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
    +1

    Result:

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    About the Creator
    Dr. Nancy Bergstrom
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