206

Part II Nutrition Assessment, Consequences, and Implications

Figure 15.2 Braden Scale for Predicting Pressure Sore Risk Patient’s Name:

Sensory perception

Ability to respond meaningfully to pressure related discomfort

1. Completely limited

Unresponsive (does

grasp) to painful stimuli due to diminished level of consciousness or sedation.

OR

Limited ability to feel pain over most of body surface.

Moisture

Degree to which skin is exposed to moisture

1. Constantly moist

Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.

Activity

Degree of physical activity

1. Bedfast Confined to bed.

Evaluator’s Name: 2. Very limited

Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness.

OR

Has sensory impairment which limits the ability to feel pain or discomfort over ½ of body.

2. Moist

Skin is often but not always moist. Linen must be changed at least once a shift.

3. Slightly limited

Date of Assessment: 4. No impairment

Responds to verbal commands but cannot always communicate discomfort or need to be turned.

OR

Has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.

3. Occasionally moist

Skin is occasionally moist, requiring an extra linen change approximately once a day.

2. Chairfast

Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheel chair.

3. Walks occasionally

Walks occasionally during day but for very short distances with or without assistance. Spends majority of each shift in bed or chair.

Mobility

Ability to change and control body position

1. Completely immobile

Does not make even slight changes in body or extremity position without assistance.

2. Very limited

Makes occasional slight changes in body or extremity position but unable to make

changes independently. 3. Slightly limited

Makes frequent though slight changes in body or extremity position

independently. 4. Rarely moist

Skin is usually dry; linen requires changing only at routine intervals.

Responds to verbal commands. Has no

which would limit ability to feel or voice pain or discomfort.

4. Walks frequently

Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours.

4. No limitations

Makes major and frequent changes in position without assistance.