1. 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