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BRADEN SCALE – For Predicting Pressure Sore Risk Use the form only for the approved purpose. Any use of the form in publications (other than internal policy manuals and training material) or for profit-making ventures requires additional permission and/or negotiation. SEVERE RISK: Total score 9 HIGH RISK: Total score 10-12
1. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of con -sciousness or sedation. OR limited ability to feel pa in over most of body . 2. Very Limited Responds only to painful stimuli.
The Braden scale is a scale that measures the risk of developing pressure ulcers. The scale consists of six subscales that reflect determinants of pressure (sensory perception, activity and mobility) and factors influencing tissue tolerance (moisture, nutrition and friction and shear).
Risk assessment is a central component of clinical practice aimed at identifying individuals susceptible to pressure injuries in order to target appropriate interventions and prevent pressure ulcer development.
Spasticity, contractures, or agitation leads to almost constant fric-tion. Very limited: Responds only to painful stimuli. Cannot communicate discomfort except by moaning or rest-lessness, OR has a sensory impair-ment which limits the ability to feel pain or discomfort over 1/2 of body.
A BIT ABOUT THE BRADEN SCALE... Six elements that contribute to either higher intensity and duration of pressure or lower tissue tolerance to pressure therefore increasing the risk of pressure ulcer development. Each item is scored between 1 and 4 guided by a descriptor. The lower the score, the greater the risk.
Braden Scale for Predicting Pressure Sore Risk. Ability to respond meaningfully to pressure related discomfort. Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. Confined to bed.
The revised scale has the same six risk assessment factors as the original Braden Scale, which is important to retain the reliability and validity of the scale. Within each of the six subsections, descriptions were updated to facilitate user scoring accuracy of the scale.
The Braden Scale is a clinician-administered assessment tool for determining a patient’s risk level for incurring skin breakdown. It has been tested in both acute care and long-term-care settings. Though the reliability of the scale has been demonstrated in a variety of settings, it has not specifically been tested with individuals with SCI.
Nursing Best Practice Guideline. Note: Individuals with a score of 18 or less are considered to be at risk of developing pressure ulcers. At risk – 15 to 18; Moderate Risk – 13 to 14; High Risk – 10 to 12; Very High Risk – 9 or below. Braden, 2001.