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Braden scale for assessing a pressure ulcer risk

1 point 2 points 3 points 4 points

Sensory sentience is missing highly limited slightly limited available

Ability to adequately respond to

• no response to painful stimuli possible • a reaction takes place only on strong pain • Reaction to speech or commands • Reaction to speech, complaints can be
pressure-related discomfort reasons: loss of consciousness, sedation or stimuli uttered or

• Disorder of pain sensation by paralysis
affecting the largest part of the body (for
example, high cross-section)
• Complaints can hardly be expressed (eg by
moaning or restlessness) or
• Disturbance of the pain sensation due to
paralysis, half of the body is affected
• However, complaints can not always be
expressed (eg that the position should be
changed) or
• no fault of pain sensation
• disorder of pain sensation due to paralysis,
of which one or two extremities are affected

humidity constantly moist often wet sometimes wet rarely humid

Extent to which the skin is exposed to moisture

• the skin is constantly wet by urine, sweat • the skin is often damp, but not always • the skin is sometimes wet, and about once a • the skin is usually dry
day, new underwear is required
or feces • new laundry is rarely needed
• always when the patient is turned, it lies in • bedding or linen must be changed per
shift at least once
the wet

activity bedridden sits on is little is regularly

Level of physical activity

• bedridden • can run something using
• its own weight can not bear alone
• needs help to sit up (bed, chair, wheelchair)
• goes a day alone, but rarely and only short • is regularly 2-3 times per shift
distances
• regularly moves
• need for longer distances • Help spends the
most time in bed or chair

mobility completely immobile Mobility severely limited Low mobility restricted mobile

Ability to change the position and to keep

• sometimes slightly moves (body or
• can also perform any slight change of extremities) • regularly makes small position change of the • can only change its position
body and extremities comprehensively
position without help • but can not regularly migrate alone is
sufficient

nutrition very poor diet moderate diet adequate nutrition Good nutrition

eating habits
• never eats on small portions, but
only 2/3
• eats only two or less servings of protein
(dairy products, fish, meat)
• drinking too little
• assumes no supplementary food to him or
• must orally do not take food to him or
• rarely eats a normal portion of food, but
eating in general, about half of the food
offered
• eat about 3 servings of protein
• regularly supplement food for themselves or
• not receive enough nutrients through tube
feedings or infusions
• eats more than half of the normal • always eats the offered meals
food portions
• takes four protein servings to be • takes 4 or more servings of
protein to be
• occasionally refused a meal, but will
supplement food to him or
• sometimes eats between meals
• can take the most nutrients across probe or • does not need supplementary food
infusions

• only clear liquids or

• receives infusions longer than 5 days

Friction and shear forces problem potential problem no problem at the time

• takes a lot to massive support postural
• Lifting is not possible without loops over the
sheets
• slips kept falling in bed or in roll / chair, has to
be pulled up again
• has spastic contractures or • is very restless
(scrubs on the sheets)
• something moves alone or need some • moving in bed and chair alone
help
• has enough strength to rise
• when pulling grinds the skin only slightly • may hold a position for a long time without
sliding down
above the sheets (can, recover)
• may be in a position hold for a long time
(chair, wheelchair)
• rarely slides down

Source: Angelika Zegelin, 1997

Decubitus hazard: low risk > 18 points

General risk 18-15 points
Average risk 14-13 points
High risk 12-10 points
Very high risk <9 points