Braden Scale
Sensory Perception help

No sensory deficits

Moisture help

Very frequent watery diarrhoea

Activity help

Can walk short distances, but spends most of day in chair

Mobility help

Only able to make small movements without assistance

Nutrition help

Eats 3/4 of every meal

Friction and Shear help

Slides a bit on sheets during lifts

Sensory Perception close

1: Completely limited: unresponsive; cannot feel pain on most of body
2: Very limited: responds to pain; cannot express pain; cannot feel pain on 1/2 of body
3: Slightly limited: responds to voice but cannot always express pain; cannot feel pain in 1 or 2 extremities
4: No impairment: alert; no sensory deficits

Moisture close

1: Constantly moist: linens changed frequently
2: Very moist: linens changed at least once a shift
3: Occasionally moist: linens changed once a day
4: Rarely moist: skin is dry; only routine linen changes

Activity close

1: Bedfast: confined to bed
2: Chairfast: can be placed into chair but cannot walk
3: Walks occasionally: can only walk short distances
4: Walks frequently: walks inside and outside room frequently

Mobility close

1: Completely immobile: cannot make even slight changes in position
2: Very limited: makes only occasional, slight changes in position
3: Slightly limited: makes frequent but only slight changes in position
4: No limitation: changes position without assistance

Nutrition close

1: Very poor: never eats more than 1/3 of meal; 2 or fewer servings of protein; NPO for 5 or more days
2: Inadequate: never eats more than 1/2 of meal; 3 servings of protein a day; sub-optimal tube feeds
3: Adequate: eats more than half of meal; 4 servings of protein a day; on tube feeds or TPN
4: Excellent: eats full meals; more than 4 servings of protein a day; may eat between meals

Friction and Shear close

1: Problem: slides frequently against sheets; requires frequent repositioning with maximum assistance
2: Potential problem: slides occasionally against sheets; requires occasional repositioning with minimal assistance
3: No apparent problem: moves independently

Braden score