Braden Scale Sensory Subsection For subsection scores 1 or 2 always apply the high risk interventions! Sensory 4 No Impairment 3 Slightly Limited 2 Very Limited 1 Completely Limited Assess Patients Ability To Respond Meaningfully To Pressure Related Discomfort! Responds to verbal command No sensory deficit which would limit ability to feel or voice pain or discomfort Responds to verbal commands Cannot always communicate discomfort or need to be turned Sensory impairment that limits ability to feel pain in 1 or 2 extremities Responds only to painful stimuli Ability to communicate discomfort limited to moaning and/or restlessness Sensory impairment that limits ability to feel pain over ½ of body Unresponsive to painful stimuli due to diminished consciousness or sedation Does not moan, flinch or grasp Limited ability to feel pain over most of body surface High Risk Interventions High Risk Low Risk Assess Patients ability to respond and perceive pain or discomfort. Subsection scores of 1 or 2 means that additional interventions should implemented regardless of the total score. Ensure heels are off of bed surfaces Ensure patient is not lying on objects and/or lines, tubes, and drains Turn every 2 hours with 30 degree tilt Select and apply appropriate surfaces Apply bordered foam to the appropriate risk areas