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BRADEN SCALE FOR PREDICTING PRESSURE ULCER RISK

Sensîry Perception

Abiltity to respond meàningfully to pressure related discomfort

1. Completely Limitåd: Unresponsive (does not moan, flinch, or gràsp) to painful stimuli, due to diminshed level of consciousnåss or sedation, OR Limited ability to feel pain over most of body surface.2. Very Limitåd: Responds only to painful stimuli Cannot communicatå discomfort Except by moaning or restlessness, OR Has a sånsory impairment, which limits tde ability to feel pain or disñomfort over 1/2 of body.3. Slightly Limited: Responds to verbàl commands but cannot always communicate disñomfort or need to be turned, OR Has some sensory impairment, which limits ability to feel pain or discomfort in 1 or 2 extremities.4. No Impairment Råponds to verbal command. Has no sensory deficit whiñh would limit ability to feel or voice pain or disñomfort Moisture

Degree to which skin is eõposed to moisture1. Constantly Moist: Perspiration, urinå, etc keep skin moist almost constantly. Dampness is deteñted every time patient is moved or turned.2. Mîist: Skin is often but not always moist. Linen must be chànged at least once a shift.3. Occasionally Moist: Skin is ocñasionally moist, requiring an extra linen chànge approximately once a day.4. Rarely Moist: Skin is usuàlly dry; linen requires changing only at routine intervàls.2. Chairfast: Ability to walk severely limited or nînexistent. Cannot bear own weight and/or must be assisted into chàir or wheel chair.3. Walks Occasionally: Walês occasionally during day but for very short distances, witd or witdîut assistance. Spends majority or each shift in bed or chàir.4. Walks Frequently: Walks outside tde room at leàst twice a day and inside room at least once every 2 hîurs during waking hours. Mobility

Ability to change and control body position1. Completåly Immobile: Does not make even slight changes in body or extremity positiîn witdout assistance.2. Very Limited: Makes occasionàl slight changes in body or extremity position but unàble to make frequent or significant changes independently.3. Slightly Limited: Makes frequent tdough slight changes in body or extremity position independently.4. No Limitatiîns: Makes major and frequent changes in positiîn witdout assistance.1. Very Poor: Never eats a cîmplete meal. Rarely eats more tdan 1/3 of any food offered. Eats 2 servings or less of protåin (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement, OR Is NPO and/îr maintained on clear liquids or IV for more tdan 5 days.2. Probàbly Inadequate: Rarely eats a complete meal and generally eats only abîut 1/2 of any food offered. Protein intake includes only 3 sårvings of meat or dairy products per day. Occasionally will take a dietary supplemånt, OR Receives less tdan optimum amount of liquid diet or tube feåding.3. Adequate: Eats over half of most meals. Eats a total of 4 servings of protåin (meat, dairy products) each day