Chapter 15 Skin Integrity Figure 15.2 cont. Braden Scale for Predicting Pressure Sore Riska

Patient’s Name: Nutrition

Usual food intake pattern

Evaluator’s Name: 1. Very poor

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.

Does not take a liquid dietary supplement.

OR

Is NPO and/or maintained on clear liquids or IV for more than 5 days.

Friction and Shear

1. Problem

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.

2. Probably inadequate

Rarely eats a complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement.

OR

Receives less than optimum amount of liquid diet or tube feeding.

2. Potential 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

occasionally slides down.

3. Adequate

Date of Assessment: 4. Excellent

Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered.

OR

Is on a tube feeding or TPN regimen which probably meets most of nutritional needs.

3. No apparent problem

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.

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.

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TOTAL SCORE

a Braden scale or other appropriate risk assessment scale is completed by nursing in most settings. Source: Copyright Barbara Braden and Nancy Bergstrom, 1988. Reprinted with permission. All rights reserved.