Patient Name:

Date of Birth: BRADEN SCALE - For Predicting Pressure Sore Risk in Home Care
NHS number:

SENSORY 1. Completely Limited 2. Very Limited 3. Slightly Limited 4. No Impairment

PERCEPTION Unresponsive (does not moan, flinch, Responds only to painful Responds to verbal commands, Responds to verbal
ability to respond or grasp) to painful stimuli, due to stimuli. Cannot communicate but cannot always communicate commands. Has no
meaningfully to diminished level of consciousness or discomfort except by moaning discomfort or the need to be sensory deficit which would
pressure-related sedation. or restlessness. turned. limit ability to feel or voice
discomfort OR OR OR pain or discomfort.
Limited ability to feel pain over most Has a sensory impairment Has some sensory impairment
of body. which limits the ability to feel which limits ability to feel pain or
pain or discomfort over 1/2 of discomfort in 1 or 2 extremities.
body.
MOISTURE 1. Constantly Moist 2. Often Moist 3. Occasionally Moist 4. Rarely Moist
degree to which Skin is kept moist almost constantly Skin is often, but not always Skin is occasionally moist, Skin is usually dry; Linen
skin is exposed to by perspiration, urine, etc. Dampness moist. Linen must be changed requiring an extra linen change only requires changing at
moisture is detected every time patient is as often as 3 times in 24 hours. approximately once a day. routine intervals.
moved or turned.
ACTIVITY 1. Bedfast 2. Chair fast 3. Walks Occasionally 4. Walks Frequently
degree of physical Confined to bed. Ability to walk severely limited Walks occasionally during day, Walks outside bedroom
activity or non-existent. Cannot bear but for very short distances, with twice a day and inside
own weight and/or must be or without assistance. Spends room at least once every
assisted into chair or majority of day in bed or chair. two hours during waking
wheelchair. hours.
MOBILITY 1. Completely Immobile 2. Very Limited 3. Slightly Limited 4. No Limitation
ability to change Does not make even slight changes Makes occasional slight Makes frequent though slight Makes major and frequent
and control body in body or extremity position without changes in body or extremity changes in body or extremity changes in position without
position assistance. position but unable to make position independently. assistance.
frequent or significant changes
independently.
NUTRITION 1. Very Poor 2. Probably Inadequate 3. Adequate 4. Excellent
usual food intake Never eats a complete meal. Rarely Rarely eats a complete meal Eats over half of most meals. Eats most of every meal.
pattern eats more than 1/3 of any food and generally eats only about Eats a total of 4 servings of Never refuses a meal.
offered. Eats 2 servings or less of 1/2 of any food offered. Protein protein (meat, dairy products Usually eats a total of 4 or
protein (meat or dairy products) per intake includes only 3 servings per day. Occasionally will refuse more servings of meat and
day. Takes fluids poorly. Does not of meat or dairy products per a meal, but will usually take a dairy products.
take a liquid dietary supplement. day. Occasionally will take a supplement when offered. Occasionally eats between
OR dietary supplement. OR meals. Does not require
Is NPO and/or maintained on clear OR Is on a tube feeding or TPN supplementation.
liquids or IV's for more than 5 days. Receives less than optimum regimen which probably meets
amount of liquid diet or tube most of nutritional needs.
feeding.
FRICTION & 1. Problem 2. Potential Problem 3. No Apparent Problem
SHEAR Requires moderate to maximum Moves feebly or requires Moves in bed and in chair
assistance in moving. Complete minimum assistance. During a independently and has sufficient
lifting without sliding against sheets is move skin probably slides to muscle strength to lift up
impossible. Frequently slides down in some extent against sheets, completely during move.
bed or chair, requiring frequent chair, restraints or other Maintains good position in bed
repositioning with maximum devices. Maintains relatively or chair
assistance. Spasticity, contractures good position in chair or bed
or agitation leads to almost constant most of the time but
friction. occasionally slides down.
Copyright Barbara Braden and Nancy Bergstrom, 1988 Total Score

Evaluator's Name: _____________________________________________ Date of Initial Assessment: _______________________