Braden Scale Score Sheet Score Total 18 risque faible entre 13 et 17 risque mod r entre 8 et 12 risque lev 7 risque tr s lev Remplissez les bulles avec les scores correspondants valuation du risque d escarre chelle de Braden PATIENT ESCARRE Nom Pr nom Pr sence d escarre au d but de la prise en charge OUI NON
BRADEN SCALE For Predicting Pressure Sore Risk SEVERE RISK Total score 9 HIGH RISK Total score 10 12 MODERATE RISK Total score 13 14 MILD RISK Total score 15 18 DATE OF ASSESS The scale consists of six subscales that reflect determinants of pressure sensory perception activity and mobility and factors influencing tissue tolerance moisture nutrition and friction and shear
Braden Scale Score Sheet
Braden Scale Score Sheet
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1 Completely Limited Unresponsive does not moan flinch or grasp to painful stimuli due to diminished level of con sciousness or sedation OR limited ability to feel pa in over most of body 2 Very Limited Responds only to painful stimuli Instructions for Using the Braden Scale for Pressure Sore Risk Obtain a copy of the Braden Scale for Pressure Sore Risk and score every sub scale item based on their descriptors Place the sub scale scores in the Score column on the far right of the table
Total score Note Individuals with a score of 18 or less are considered to be at risk of developing pressure ulcers At risk 15 to 18 Moderate Risk 13 to 14 High Risk 10 to 12 Very High Risk 9 or below Instruct to turn and reposition at least every 2 4 hours on a pressure reducing mattress or 2 hours while in bed or chair Inspect bony prominences every day visit Place at risk individuals on pressure reduction surface Refer to Physical and or Occupational Therapist
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Braden Scale BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK Patient s
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BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK Source The Hartford Institute of Geriatric Nursing Barbara Braden and Nancy Bergstrom 1988 Patient s Name Evaluator s Name Date of Assessment SENSORY PERCEPTION ability to respond meaningfully to pressure related discomfort 1 Completely Limited A BIT ABOUT THE BRADEN SCALE Six elements that contribute to either higher intensity and duration of pressure or lower tissue tolerance to pressure therefore increasing the risk of pressure ulcer development Each item is scored between 1 and 4 guided by a descriptor The lower the score the greater the risk
1 Completely Limited 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 2 Very Limited Responds only to painful stimuli The Braden score calculator helps to identify patients at risk of pressure ulcers The Braden scale for predicting pressure ulcer risk consists of six sub scales related to factors associated with pressure ulcer development which include sensory perception moisture activity mobility nutrition and friction shear
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Braden Scale Score Sheet
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Score Total 18 risque faible entre 13 et 17 risque mod r entre 8 et 12 risque lev 7 risque tr s lev Remplissez les bulles avec les scores correspondants valuation du risque d escarre chelle de Braden PATIENT ESCARRE Nom Pr nom Pr sence d escarre au d but de la prise en charge OUI NON
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BRADEN SCALE For Predicting Pressure Sore Risk SEVERE RISK Total score 9 HIGH RISK Total score 10 12 MODERATE RISK Total score 13 14 MILD RISK Total score 15 18 DATE OF ASSESS
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Braden Scale Score
Braden Scale Score Sheet - Total score Note Individuals with a score of 18 or less are considered to be at risk of developing pressure ulcers At risk 15 to 18 Moderate Risk 13 to 14 High Risk 10 to 12 Very High Risk 9 or below
