Reimbursement Help I

Braden Pressure Ulcer Risk Assessment

NOTE: Bed and chairbound individuals or those with impaired ability to reposition should be assessed upon admission for their risk of developing pressure ulcers. Patients with established pressure ulcers should be reassessed periodically.

Sensory Perception

1. Completely Limited

2. Very Limited

3. Slightly Limited

4. No Impairment

Ability to respond meaningfully to pressure-related discomfort

Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation, OR Limited ability to feel pain over most of body surface

Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness, OR Has a sensory impairment which limits the ability to feel pain or discomfort over ½ of body.

Responds to verbal commands but cannot always communicate discomfort or need to be turned, OR Has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.

Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.

Moisture

1. Constantly moist

2. Moist

3. Occasionally moist

4. Rarely moist

Degree to which skin is exposed to moisture

Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.

Skin is often but not always moist. Linen must be changed at least once a shift.

Skin is occasionally moist, requiring an extra linen change approximately once a day.

Skin is usually dry; linen requires changing only at routine intervals.

Activity

1. Bedfast

2. Chairfast:

3. Walks occasionally

4. Walks frequently

Degree of physical activity

Confined to bed.

Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.

Walks occasionally during day but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.

Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours.

®Copyright Barbara Braden and Nancy Bergstrom, 1988 All rights reserved

Mobility

1. Completely Immobile

2. Very limited

3. Slightly limited

4. No limitations

Ability to change and control body position

Does not make even slight changes in body or extremity position without assistance.

Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

Makes frequent though slight changes in body extremity position independently.

Makes major and frequent changes in position without assistance.

Nutrition

1. Very poor

2. Probably Inadequate

3. Adequate

4. Excellent

Usual food intake pattern

Never eats a complete meal. Rarely eats more than ⅓ of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement, OR Is NPO1 and/or maintained on clear liquids or IV2 for more than 5 days.

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.

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 of offered, OR Is on a tube feeding or TPN3 regimen, which probably meets most of nutritional needs.

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.

Friction and Shear

1. Problem

2. Potential problem

3. No apparent problem

Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequent slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction.

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 of the time but occasionally slides down.

Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in be or chair at all times.

NOTE: Patients with a total score of 16 or less are considered to be at risk of developing pressure ulcers.

(15 or 16 = low risk; 13 or 14 = moderate risk; 12 or less = high risk)

Total Score:

 

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