Braden Scale assessment: a step-by-step guide for SNF nurses

How well does the resident respond to pressure-related discomfort?

• 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 the body.
• 2 — Very limited. Responds only to painful stimuli; cannot communicate discomfort except by moaning or restlessness, OR has a sensory impairment that limits ability to feel pain over half the body.
• 3 — Slightly limited. Responds to verbal commands but cannot always communicate discomfort, OR has some sensory impairment that limits ability to feel pain in 1 or 2 extremities.
• 4 — No impairment. Responds to verbal commands; has no sensory deficit that would limit ability to feel or voice pain.

How often is skin exposed to moisture (sweat, urine, drainage)?

• 1 — Constantly moist. Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time the resident is moved or turned.
• 2 — Very moist. Skin is often, but not always, moist. Linen must be changed at least once a shift.
• 3 — Occasionally moist. Skin is occasionally moist, requiring an extra linen change approximately once a day.
• 4 — Rarely moist. Skin is usually dry; linen only requires changing at routine intervals.

What is the resident's degree of physical activity?

• 1 — Bedfast. Confined to bed.
• 2 — Chairfast. Ability to walk is severely limited or non-existent; cannot bear own weight and must be assisted into chair or wheelchair.
• 3 — Walks occasionally. Walks occasionally during the day but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.
• 4 — Walks frequently. Walks outside the room at least twice a day and inside the room at least once every two hours during waking hours.

How well can the resident change and control body position?

• 1 — Completely immobile. Does not make even slight changes in body or extremity position without assistance.
• 2 — Very limited. Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.
• 3 — Slightly limited. Makes frequent though slight changes in body or extremity position independently.
• 4 — No limitation. Makes major and frequent changes in position without assistance.

What is the resident's usual food intake pattern?

• 1 — Very poor. Never eats a complete meal. Rarely eats more than 1/3 of food offered. Eats 2 servings or less of protein per day. Takes fluids poorly or is NPO/IV for more than 5 days.
• 2 — Probably inadequate. Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally takes a dietary supplement, OR receives less than optimum amount of liquid diet or tube feeding.
• 3 — Adequate. Eats over half of most meals. Eats a total of 4 servings of protein per day. Occasionally refuses a meal but will usually take a supplement if offered, OR is on a tube feeding or TPN regimen that probably meets most nutritional needs.
• 4 — Excellent. Eats most of every meal. Never refuses a meal. Usually eats 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.

How much friction and shear is the resident exposed to during repositioning?

• 1 — Problem. Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning. Spasticity, contractures, or agitation lead to almost constant friction.
• 2 — Potential problem. 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.
• 3 — No apparent problem. Moves in bed and chair independently and has sufficient muscle strength to lift up completely during a move. Maintains good position in bed or chair at all times.