Sensory Perception

Abiltity to respond
meaningfully to pressure
related discomfort

1.  Completely Limited:
Unresponsive (does not moan, flinch, or
grasp) to painful stimuli, due to diminshed
level of consciousness or sedation,
Limited ability to feel pain over most of body

2.  Very Limited:
Responds only to painful stimuli
Cannot communicate discomfort
Except by moaning or restlessness,
Has a sensory impairment, which limits
the ability to feel pain or discomfort
over 1/2 of body.
3.  Slightly Limited:
Responds to verbal commands but cannot always communicate
discomfort or need to be turned,
Has some sensory impairment, which
limits ability to feel pain or
discomfort in 1 or 2 extremities.
4.  No Impairment
Reponds to verbal
command.  Has no
sensory deficit which
would limit ability to
feel or voice pain or

Degree to which skin is
exposed to moisture

1.  Constantly Moist:
Perspiration, urine, etc keep skin moist
almost constantly.  Dampness is detected
every time patient is moved or turned.
2.  Moist:
Skin is often but not always moist.
Linen must be changed at least once a
3.  Occasionally Moist:
Skin is occasionally moist, requiring
an extra linen change approximately
once a day.
4.  Rarely Moist:
Skin is usually dry;
linen requires changing
only at routine intervals.

Degree of physical

1.  Bedfast
Confined to bed.
2.  Chairfast:
Ability to walk severely limited or
nonexistent.  Cannot bear own weight
and/or must be assisted into chair or
wheel chair.
3.  Walks Occasionally:
Walks occasionally during day but
for very short distances, with or
without assistance.  Spends majority
or each shift in bed or chair.
4.  Walks Frequently:
Walks outside the room
at least twice a day and
inside room at least
once every 2 hours
during waking hours.

Ability to 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
4.  No Limitations:
Makes major and
frequent changes in
position without

Usual food intake pattern

1.  Very Poor:
Never eats a complete meal.  Rarely eats
more than 1/3 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,
Is NPO and/or maintained on clear liquids or
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 will take a dietary supplement,
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 (meat,
dairy products) each day.
Occasionally will refuse a meal, but
will usually take a supplement if offered,
Is on a tube feeding or TPN regimen,
which probably meets most of
nutritional needs.
4. Excellent:
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
Friction and Shear 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 with maximum
assistance.  Spasticity, contractures, or
agitation leads 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 in chair
independently and has sufficient muscle strength to lift up completely during move.   Maintains good
position in bed or chair at all times.

   Perform Braden Scale on admission, quarterly, after major change, after return from Hospital                                                                  
     When Braden Scale Score 16 or less, implement Pressure Ulcer Prevention Protocols
     1)  Circle type of pressure reduction device used:
          State Air, Alternating Pressure, Low Air Loss Mattress, Other ____________  Date: _______ Initials: ________
     2)  Nutritional Consult ordered:  Date: _______ Initials: ________ Date: _____ Initials: _______
     3)  (15-16 = low risk, 13-14 = moderate risk, 12 or less = high risk)

ACWCP - 1998