BRADEN SCALE FORM

SEVERE RISK: TOTAL SCORE ≤ 9 HIGH RISK: TOTAL SCORE 10-12 DATE OF
MODERATE RISK: TOTAL SCORE 13-14 MILD RISK: TOTAL SCORE 15-18 ASSESSMENT:
RISK FACTOR SCORE/DESCRIPTION
SENSORY 1. COMPLETELY 2. VERY LIMITED 3. SLIGHTLY LIMITED 4. NO IMPAIRMENT
PERCEPTION LIMITED Unresponsive (does not Responds only to painful Responds to verbal Responds to verbal
Ability to moan, flinch or grasp) to painful stimuli, due stimuli. Cannot communicate commands but cannot commands. Has no
to diminished level of discomfort except by moaning or always communicate sensory deficit which
respond consciousness or sedation, restlessness, OR discomfort or need to be turned, would limit ability to feel or
meaningfully to OR has a sensory impairment OR as some sensory voice pain or discomfort.
pressure-related limited ability to feel pain over most of body which limits the ability to impairment which limits
discomfort surface. feel pain or discomfort over ½ of ability to feel pain or
body. discomfort in 1 or 2 extremities.

MOISTURE 1.CONSTANTLY MOIST 2. OFTEN MOIST 3.OCCASIONALLY MOIST 4. RARELY MOIST Skin
Degree to which Skin is kept moist almost constantly by Skin is often but not always moist. Skin is occasionally moist, is usually dry; linen only
skin is exposed to perspiration, urine etc. Dampness is detected Linen must be changed at least once requiring an extra linen requires changing at
moisture every time patient is moved or turned. a shift. change approximately once a day. routine intervals.

ACTIVITY 1. BEDFAST 2. CHAIRFAST 3. WALKS 4. WALKS

Degree of physical Confined to bed. Ability to walk severely limited or OCCASIONALLY Walks FREQUENTLY
activity nonexistent. Cannot bear own occasionally during day, but for very Walks outside the room at
weight and/or must be assisted into short least
chair or wheelchair. distances, with or without twice a day and inside
assistance. Spends room at least once every 2
majority of each shift in bed or chair. hours during waking hours.

MOBILITY 1.COMPLETELY 2. VERY LIMITED Makes 3. SLIGHTLY LIMITED Makes 4. NO LIMITATIONS

Ability to IMMOBILE Does not make occasional slight frequent though Makes major and frequent
change even slight changes in body or extremity changes in body or slight changes in body or xtremity changes in position without
position without assistance. extremity position but position assistance.
and control body unable to make frequent or independently.
position significant changes
independently.

NUTRITION 1. VERY POOR 2. PROBABLY INADEQUATE 3. ADEQUATE Eats over 4. EXCELLENT Eats
Usual food intake Never eats a complete meal. Rarely eats a complete meal and half of most meals. most of every meal.
pattern Rarely eats more than 1/3 generally eats only about ½ of any Eats a total of 4 servings of protein Never refuses a meal. Usually
1
NPO: Nothing by of any food offered. Eats food offered. (meat, dairy products) each day. eats a total of 4 or
2 servings or less of protein (meat or dairy Protein intake includes only 3 Occasionally refuses a meal, but will more servings of meat and
mouth. products) per day. Takes fluids poorly. Does usually take a supplement if offered, dairy products. Occasionally
2
IV: Intravenously. servings of meat or dairy products
not take a liquid dietary supplement, per day. Occasionally will take a OR eats between meals. Does not
3
TPN: Total OR dietary supplement is on a tube feeding or TPN 3 require supplementation.
parenteral is NPO 1 and/or maintained on clear liquids OR regimen, which probably meets most
nutrition or IV 2 for more than 5 days. receives less than optimum amount of nutritional needs.
of liquid diet or tube feeding.

FRICTION AND 1. PROBLEM 2. POTENTIAL 3. NO APPARENT PROBLEM

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.
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.
Moves in bed and in chair
independently and has
sufficient muscle strength
to lift up completely during move.
Maintains good position in bed or
chair at all times.

TOTAL
TOTAL SCORE OF 12 OR LESS REPRESENT HIGH RISK
SCORE