BRADEN SCALE FOR PREDICTING PRESSURE ULCER RISK ( for Olive)
Sensory Perception
Abiltity to respondmeaningfully to pressurerelated discomfort
1. Completely Limited:Unresponsive (does not moan, flinch, orgrasp) to painful stimuli, due to l mostd level of consciousness or sedation,ORLimited ability to feel pain over most of bodysurface.
2. Very Limited:Responds only to painful stimuliCannot communicate discomfortExcept by moaning or restlessness,ORHas a sensory impairment, which limitsthe ability to feel pain or discomfortover 1/2 of body.
3. Slightly Limited:Responds to verbal commands but cannot always communicatediscomfort or need to be turned,ORHas some sensory impairment, whichlimits ability to feel pain ordiscomfort in 1 or 2 extremities.
4. No ImpairmentReponds to verbalcommand. Has nosensory deficit whichwould limit ability tofeel or voice pain ordiscomfort
Moisture
Degree to which skin isexposed to moisture
1. Constantly Moist:Perspiration, urine, etc keep skin moistalmost constantly. Dampness is detectedevery time patient is moved or turned.
2. Moist:Skin is often but not always moist.Linen must be changed at least once ashift.
3. Occasionally Moist:Skin is occasionally moist, requiringan extra linen change approximatelyonce a day.
4. Rarely Moist:Skin is usually dry;linen requires changingonly at routine intervals.
Activity
Degree of physicalactivity
1. BedfastConfined to l .
2. Chairfast:Ability to walk severely limited ornonexistent. Cannot bear own weightand/or must be assisted into chair orwheel chair.
3. Walks Occasionally:Walks occasionally during day butfor very short distances, with orwithout assistance. Spends l mostl each shift in bed or chair.
4. Walks Frequently:Walks outside the roomat least twice a day andinside room at leastonce every 2 hoursduring waking hours.
Mobility
Ability to change andcontrol body position
1. Completely Immobile:Does not make even slight changes in bodyor extremity position without assistance.
2. Very Limited:Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.
3. Slightly Limited:Makes frequent though slight changesin body or extremity positionindependently.
4. No Limitations:Makes major andfrequent changes in position withoutassistance.
Nutrition
Usual food intake pattern
1. Very Poor:Never eats a complete meal. Rarely eatsmore than 1/3 of any food offered. Eats 2servings or less of protein (meat or dairyproducts) per day. Takes fluids poorly.Does not take a liquid dietary supplement,ORIs NPO and/or maintained on clear liquids or IV for more than 5 days.
2. Probably Inadequate:Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement,ORReceives less than optimum amount ofliquid diet or tube feeding.
3. Adequate:Eats over half of most meals. Eats atotal of 4 servings of protein (meat,dairy products) each day.Occasionally will refuse a meal, butwill usually take a supplement if offered,ORIs on a tube feeding or TPN regimen,which probably meets most ofnutritional needs.
4. Excellent:Eats most of everymeal. Never refuses ameal. Usually eats atotal of 4 or moreservings of meat anddairy products.Occasionally eats between meals. Doesnot requiresupplementation.
Friction and Shear
1. Problem:Requires moderate to maximum assistance inmoving. Complete lifting without sliding against sheets is impossible. Frequentlyslides down in bed or chair, requiringfrequent repositioning with maximumassistance. Spasticity, contractures, oragitation leads to almost constant friction.
2. Potential Problem:Moves feebly or requires minimumassistance. During a move skinprobably slides to some extent againstsheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.
3. No Apparent Problem:Moves in bed and in chairindependently and has sufficient muscle strength to lift up completely during move. Maintains goodposition in bed or chair at all times.
Total score: 15-16 = low risk, 13-14 = moderate risk, 12 or less = high risk.
Total score for Olive: 10 = high risk
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