Braden Pressure Injury Risk Assessment

Completely limited

Unresponsive (no reaction) to painful stimuli or limited ability to feel pain over most of body.

Very limited

Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness.

Slightly limited

Responds to verbal commands but may not feel some areas of body.

Constantly moist

Skin kept moist almost constantly by perspiration, urine, etc.

Very moist

Skin often moist; requires frequent linen changes.

Occasionally moist

Skin occasionally moist; requires extra linen change once a day.

Bedfast

Confined to bed.

Chairfast

Ability to walk severely limited or nonexistent.

Walks frequently

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

Completely immobile

Does not make even slight changes in body or extremity position.

Very limited

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

No limitations

Makes major and frequent changes in position without assistance.

Very poor

Never eats a complete meal. Rarely eats more than ½ of food offered.

Probably inadequate

Rarely eats a complete meal and generally eats only about ½ of food offered.

Excellent

Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of protein.

Problem

Requires moderate to maximum assistance in moving.

Potential problem

Moves feebly or requires minimum assistance. During a move skin probably slides to some extent.