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    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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    Formula

    Addition of the selected points:

    Variable

    Points

    Sensory perception

    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

    Moisture

    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

    Activity

    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

    Mobility

    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

    Nutrition

    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

    Friction & shear

    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

    Facts & Figures

    Interpretation:

    Braden Score

    Risk Group

    ≤12

    High

    13-15

    Moderate

    16-17

    Mild

    ≥18

    Average

    Note: universal cutoffs are not prescribed for the Braden Scale, and institutions are encouraged to conduct their own studies in order to determine optimal cutoff points. This stratification is one suggestion from a prospective study by the original authors (Bergstrom 1992).

    Literature

    Validation

    Research PaperBergstrom N, Braden BJ. Predictive validity of the Braden Scale among Black and White subjects. Nurs Res. 2002;51(6):398-403.Research PaperBergstrom N, Braden B, Kemp M, Champagne M, Ruby E. Predicting pressure ulcer risk: a multisite study of the predictive validity of the Braden Scale. Nurs Res. 1998;47(5):261-9.Research PaperHyun S, Vermillion B, Newton C, et al. Predictive validity of the Braden scale for patients in intensive care units. Am J Crit Care. 2013;22(6):514-20.Research PaperKring DL. Reliability and validity of the Braden Scale for predicting pressure ulcer risk. J Wound Ostomy Continence Nurs. 2007;34(4):399-406.Research PaperGriswold LH, Griffin RL, Swain T, Kerby JD. Validity of the Braden Scale in grading pressure ulcers in trauma and burn patients. J Surg Res. 2017;219:151-157.Research PaperBergstrom N, Braden B. A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc. 1992;40(8):747-58.
    Dr. Nancy Bergstrom

    About the Creator

    Nancy Bergstrom, PhD, RN, FAAN, is a retired associate dean of research at UTHealth School of Nursing and director of the Center on Aging at the University of Texas Health Science Center. She was also inducted into the Nursing Research Hall of Fame. Dr. Bergstrom’s research was focused primarily on pressure ulcer reduction.

    To view Dr. Nancy Bergstrom's publications, visit PubMed