Braden Scale

4 No impairment — responds to verbal commands; no sensory deficit. 3 Slightly limited — responds to verbal commands but cannot feel discomfort in one or two extremities. 2 Very limited — responds only to painful stimuli; cannot communicate discomfort. 1 Completely limited — unresponsive to painful stimuli due to diminished consciousness or sedation.

4 Rarely moist — skin is usually dry; linen changed at routine intervals. 3 Occasionally moist — skin is occasionally moist, requiring an extra linen change about once a day. 2 Very moist — skin is often but not always moist; linen changed at least once per shift. 1 Constantly moist — perspiration, urine, or drainage keeps skin moist continuously.

4 Walks frequently — walks outside room at least twice daily and inside room every two hours. 3 Walks occasionally — walks occasionally during day but for very short distances, with or without assistance. 2 Chairfast — ability to walk severely limited; cannot bear own weight and must be assisted into chair or wheelchair. 1 Bedfast — confined to bed.