What is the Braden Scale?
Monday, 26 March 2018
If you or someone you are caring for is temporarily or permanently confined to a bed or wheelchair, pressure sores are a real possibility you want to avoid at all costs. Pressure sores, also known as pressure ulcers, pressure injuries, bedsores or decubitus ulcers, occur due to pressure applied to soft tissues, resulting in completely or partially obstructed blood flow to the tissue.
Luckily, this can be easily prevented by using numerous pressure relief products available on the market, but first it's important to know how serious the risk of developing a pressure ulcer is. This short article will help you learn how to evaluate the patient's risk of developing a sore, and find the best possible solution to prevent this from happening.
What is the Braden Scale?
Simply put, the Braden Scale is a test developed to help professionals, especially nurses and caretakers, asses the patient's risk of developing a pressure ulcer by examining six criteria. The total score can range from six to 23, with the lower score indicating a higher risk.
Criteria for Assessment
You can use the table below to assess your or your patient's risk of developing a pressure ulcer right away. While we advise consulting your GP or specialist whenever possible, this offers a quick view into the current situation.
|Risk Factor ||Score 1 ||Score 2 ||Score 3 ||Score 4 |
|Sensory Perception ||Completely Limited ||Very Limited ||Slightly Limited ||No Impairment |
|Moisture ||Constantly Moist ||Often Moist ||Occasionally Moist ||Rarely Moist |
|Activity ||Bedfast ||Chairfast ||Walks Occasionally ||Walks Frequently |
|Mobility ||Completely Immobile ||Very Limited ||Slightly Limited ||No Limitations |
|Nutrition ||Very Poor ||Probably Inadequate ||Adequate ||Excellent |
|Friction and Shear ||Problem ||Potential Problem ||No Apparent Problem || |
- Sensory perception evaluates the patient's ability to respond meaningfully to pressure-related discomfort.
- Completely limited: limited ability to feel pain over most of the body.
- Very limited: has a sensory impairment which limits the ability to feel pain or discomfort over half of the body.
- Slightly limited: has some sensory impairment which limits the ability to feel pain or discomfort in one or two extremities.
- No impairment: has no sensory deficit which would limit ability to feel or voice pain or discomfort.
- Moisture evaluates the degree to which the skin is exposed to moisture.
- Constantly moist: skin is kept moist almost constantly by perspiration, urine, etc.
- Often moist: Skin is often but not always moist.
- Occasionally moist: skin is occasionally moist, requiring an extra linen change approximately once a day.
- Rarely moist: skin is usually dry.
- Activity evaluates the degree of physical sensitivity.
- Bedfast: confined to bed.
- Chairfast: the ability to walk is severely limited or nonexistent.
- Walks occasionally: walks occasionally during the day, but for very short distances, with or without assistance.
- Walks frequently: walks outside the room at least twice a day.
- Mobility evaluates the patient's ability to change and control their body position.
- Completely immobile: does not make even slight changes in body or extremity position without assistance.
- Very limited: makes occasional slight changes in body or extremity position but is unable to make frequent or significant changes.
- Slightly limited: makes frequent though slight changes in body or extremity position independently.
- No limitations: Makes major and frequent changes.
- Nutrition evaluates the usual intake pattern.
- Very poor: the patient is maintained on clear liquids or IV for more than five days.
- Probably inadequate: rarely eats a complete meal and generally eats only about half of any food offered.
- Adequate: eats over half of most meals.
- Excellent: eats most of every meal. Never refuses a meal.
- Friction and shear
- Problem: requires moderate to maximum assistance in moving.
- Potential problem: moves freely or requires minimum assistance.
- No apparent problem: moves in bed and in chair independently.
Braden Scale Score Range
Each category is rated on a scale of one to four, or one to three in case of the last one, which combines a possible total of 23 points. A score of 23 means there is no risk for developing a pressure ulcer, while a lower score signifies a possible problem. The Braden Scale assessment score scale is as follows:
|Potential Risk ||Score |
|Very High Risk ||9 or less |
|High Risk ||10 - 12 |
|Moderate Risk ||13 - 14 |
|Mild Risk ||15 - 18 |
|No Risk ||19 - 23 |
How Can I Prevent Pressure Sores?
If you believe you or a person you are caring for is at risk for developing pressure ulcers, we advise you to consult a doctor to find the best possible solution. In some milder cases, however, pressure ulcers can be prevented and treated with proper care and use of pressure relief aids.
The action you want to take depends on the results of the test:
Braden Score 15 - 18 (Mild Risk)
- Manage the patient's moisture, nutrition, friction and shear
Braden Score 13 - 14 (Moderate Risk)
- Use the same protocol as for patients at mild risk
- Position the patient at 30° lateral incline using foam wedges
Braden Score 10 - 12 (High Risk)
- Use the same protocol as for patients at moderate risk
- When turning the patient, make small shifts in their position as well
Braden Score 9 or Less (Very High Risk)
Supporting any part of the body, be it the hips, heels, elbows, back or the coccyx, that is in constant contact with a hard surface is the most important aspect when it comes to caring for a patient who is at risk. To find a possible solution for preventing or treating a milder sore, explore our range of products that specialise in Pressure Relief, and include everything from Wheelchair Fleeces to Memory Foam Mattresses and Heel Protectors.
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