braden scale
4. Excellent
nutrition - Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more
servings of meat and dairy products. Occasionally eats between meals. Does not require
supplementation.
4. No impairment:
sensory perception - Responds to verbal
commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort
4. Rarely moist:
moisture - Skin is usually dry; linen requires changing only at routine intervals.
4. Walks frequently:
activity - Walks outside the room at least twice a day and inside room at least once every 2
hours during waking hours.
6-23 - this is the range of the braden scale
activity - bed fast
chair fast
walks occasionally
walk frequently
Activity - Degree of physical activity
, bedfast
Activity - Confined to bed.
1. Completely immobile:
mobility - Does not make even slight changes in body or extremity position without assistance.
1. Completely limited:
sensory perception - Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to
diminished level of consciousness or sedation,
OR
limited ability to feel pain over most of body surface.
1. Constantly moist
Moisture - Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected
every time patient is moved or turned.
1. Problem: Friction and shear - 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. Very poor nutrition - Never eats a complete meal. Rarely eats more than 1/3 of any food
offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly.
Does not take a liquid dietary supplement,
OR
is NPO[1] and/or maintained on clear liquids or IV[2] for more than 5 days.
4. Excellent
nutrition - Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more
servings of meat and dairy products. Occasionally eats between meals. Does not require
supplementation.
4. No impairment:
sensory perception - Responds to verbal
commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort
4. Rarely moist:
moisture - Skin is usually dry; linen requires changing only at routine intervals.
4. Walks frequently:
activity - Walks outside the room at least twice a day and inside room at least once every 2
hours during waking hours.
6-23 - this is the range of the braden scale
activity - bed fast
chair fast
walks occasionally
walk frequently
Activity - Degree of physical activity
, bedfast
Activity - Confined to bed.
1. Completely immobile:
mobility - Does not make even slight changes in body or extremity position without assistance.
1. Completely limited:
sensory perception - Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to
diminished level of consciousness or sedation,
OR
limited ability to feel pain over most of body surface.
1. Constantly moist
Moisture - Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected
every time patient is moved or turned.
1. Problem: Friction and shear - 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. Very poor nutrition - Never eats a complete meal. Rarely eats more than 1/3 of any food
offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly.
Does not take a liquid dietary supplement,
OR
is NPO[1] and/or maintained on clear liquids or IV[2] for more than 5 days.
