<html>
<head>
<meta charset="UTF-8"/>
<meta name="tikaGenerated" content="true"/>
<meta name="date" content="2014-10-08T01:53:05Z"/>
<meta name="creator" content="svellom"/>
<meta name="xmp:CreatorTool" content="Acrobat PDFMaker 10.1 for Word"/>
<meta name="Company" content="SA Health"/>
<meta name="meta:author" content="svellom"/>
<meta name="meta:creation-date" content="2014-10-08T01:52:47Z"/>
<meta name="created" content="Wed Oct 08 12:22:47 ACDT 2014"/>
<meta name="dc:creator" content="svellom"/>
<meta name="xmpTPg:NPages" content="1"/>
<meta name="Creation-Date" content="2014-10-08T01:52:47Z"/>
<meta name="dcterms:created" content="2014-10-08T01:52:47Z"/>
<meta name="Last-Modified" content="2014-10-08T01:53:05Z"/>
<meta name="dcterms:modified" content="2014-10-08T01:53:05Z"/>
<meta name="title" content="MODIFIED BRADEN Q PRESSURE ULCER RISK ASSESSMENT SCALE"/>
<meta name="Last-Save-Date" content="2014-10-08T01:53:05Z"/>
<meta name="Created" content="D:20100624"/>
<meta name="LastSaved" content="D:20141008"/>
<meta name="meta:save-date" content="2014-10-08T01:53:05Z"/>
<meta name="SourceModified" content="D:20141008012132"/>
<meta name="dc:title" content="MODIFIED BRADEN Q PRESSURE ULCER RISK ASSESSMENT SCALE"/>
<meta name="Author" content="svellom"/>
<meta name="producer" content="Adobe PDF Library 10.0"/>
<meta name="modified" content="2014-10-08T01:53:05Z"/>
<meta name="Content-Type" content="application/pdf"/>
</head>
<body>
<pre>
 
MODIFIED BRADEN Q PRESSURE ULCER RISK ASSESSMENT SCALE 
For children &lt; 5 years 

 

Category Descriptor Score 

Mobility Completely  immobile:  Does  not  make  even  slight  changes  in  body  or  extremity  position  without 
assistance. 
Very limited: Makes occasional slight changes in body or extremity position but unable to completely turn self 
independently. 
Slightly limited: Makes frequent though slight changes in body or extremity position independently. 
No limitations: makes major and frequent changes in position without assistance. 

1 
2 

 
3 
4 

Activity Bedfast: confined to bed. 
Chairfast:   Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be 
assisted into chair or wheelchair. 
Walks  occasionally:  walks  occasionally  during  day,  but  for  very  short  distances,  with  or  without 
assistance. Spends majority of each shift in bed or chair. 
All patients too young to ambulate:  OR walks frequently. Walks outside the room at least twice a day. 

1 
2 

 
3 

 
4 

Sensory 
Perception 

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 surface. 
Very Limited: Responds to only painful stimuli. Cannot communicate discomfort except by moaning or 
restlessness; OR has sensory impairment that limits the ability to feel pain or discomfort over half of body. 
Slightly Limited: Responds to verbal commands, but cannot always communicate discomfort or need to be 
turned; OR, has sensory impairment that limits the ability to feel pain or discomfort in one or two 
extremities. 
No Impairment: Responds to verbal commands. Has no sensory deficit that would limit ability to feel or 
communicate pain or discomfort.. 

1 
 

2 
 

3 
 

4 

Moisture Constantly moist: skin is kept moist almost constantly by perspiration, urine, drainage etc. Dampness is 
detected every time patient is moved or turned. 
Very moist: Skin is often, but not always, moist. Linen must be changed at least every 8 hours. 
Occasionally moist: Skin is occasionally moist, requiring linen change every 12 hours. 
Rarely moist: Skin is usually dry, routine diaper changes; linen only requires changing every 24 hours. 

1 
 

2 
3 
4 

Friction 
Shear 

Significant problem: spasticity, contractures, itching or agitation leads to almost constant thrashing and 
friction. 
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. 
Potential problem: Moves feebly or requires minimum assistance. During a move, skin probably slides to some 
extent against sheets, chair, restraint or other devices. Maintains relative good position in chair or bed most of 
the time but occasionally slides down. 
No apparent problem: Able to completely lift patient during a position change, moves in bed and in chair 
independently and has sufficient muscle strength to lift completely during move. Maintains good position in bed or 
chair at all times. 

1 
 

2 
 
 

3 
 
 

4 

Nutrition Very poor: NPO and/or maintained on clear fluids, or IVs for more than 5 days OR albumin &lt; 2.5 mg/dl OR 
never eats a complete meal. Rarely eats more than half of any food offered. Protein intake includes only 2 
servings of meat or dairy products per day. Takes fluids poorly. Does not take a liquid dietary supplement.. 
Inadequate: Is on a liquid diet or tube feedings/TPN, which provide inadequate calories and minerals for age 
OR albumin&lt;3mg/dl OR rarely eats a complete meal and generally eats only half of any food offered. Protein 
intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. 
Adequate: Is on tube feedings or TPN, which provides adequate calories and minerals for age OR eats over half 
of most meals. Eats a total of 4 servings of protein each day. Occasionally eats between meals. Does not require 
supplementation. 
Excellent:: Is on a normal diet providing adequate calories for age. For example, 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 supplementation. 

1 
 
 
 

2 
 
 
 

3 
 
 

4 

Tissue 
perfusion &amp; 
oxygenation 

Extremely  compromised:  Hypotensive  (MAP&lt;50mmHg;  &lt;40  in  newborn)  or  the  patient  does  not 
physiologicvally tolerate position changes. 
Compromised: Normotensive oxygen saturation may be &lt;95%; haemoglobin may be &lt;10mg/dl; capillary refill 
may be&gt; 2 seconds; serum pH is &lt; 7.40. 
Adequate: Normotensive oxygen saturation may be &lt;95%; haemoglobin may be &lt;10mg/dl; capillary refill may 
be 2 seconds; serum pH is normal. 
Excellent:: Normotensive, oxygen saturation &gt;95%; normal haemoglobin; capillary refill &lt;2 seconds. 

1 
 

2 
 

3 
 

4 
 

Risk score: 16 or greater at low risk 
  Quigley S &amp; Curley M. 1996, Reprinted with permission, PUPPIES collaborative 2005 


</pre>
</body>
</html>