Bra
den
Sca
le f
or
Pre
dic
ting
Pre
ssur
e U
lcer
Ris
k Category I (Stage I)
Category II(Stage II)
Category III(Stage III)
Category IV(Stage IV)
Unclassified(Unstageable)
Suspected Deep Tissue Injury
© Copyright Barbara Braden and Nancy Bergstrom, 1988 All rights reserved
Caustic Fluids (Stool, Urine, Gastric)Moisture Score Action
1
Continuously moist perineum
• Continuous diarrhea• Continuous urine
1. Immediate cleansing with Baza Cleanse & Protect® Lotion
2. Fecal/Urinary containment
3. If skin is broken, apply a skin protectant barrier such as Critic-Aid® Clear Ointment
4. Re-apply q shift or PRN
2
Very moist perineum
• Frequent diarrhea• Peri-wound exposure
1. Immediate cleansing with Baza Cleanse & Protect Lotion
2. Fecal/Urinary containment
3. If skin is broken, apply a skin protectant barrier such as Critic-Aid Clear Ointment
4. Re-apply q shift or PRN
3
Occasionally moist perineum
• Infrequent diarrhea• Infrequent urine
1. Immediate cleansing with Baza Cleanse & Protect Lotion
2. If skin is broken, apply a skin protectant barrier such as Critic-Aid Clear Ointment
3. Re-apply q shift or PRN
Hig
h R
isk
Low
Ris
k
Non-Caustic Fluids (Sweat)Moisture Score Action
1
Continuously moist skin fold
• Obese • Bedridden
1. Cleanse skin fold area with Bedside-Care® Foam
2. Apply InterDry® Ag Textile
3. Change InterDry Ag q 5 d and PRN
4. Continue to assess daily
2
Very moist skin fold
• Contracture of groin or axilla
• Redundant breast
1. Cleanse skin fold area with Bedside-Care Foam
2. Apply InterDry Ag Textile
3. Change InterDry Ag q 5 d and PRN
4. Continue to assess daily
3
Occasionally moist skin fold
• Braces• Armpits• Back of knees
1. Cleanse skin fold area with Bedside-Care Foam
2. Apply InterDry Ag Textile
3. Change InterDry Ag Textile q 5 d and PRN
4. Continue to assess daily if possible
Protocol for Braden Moisture SubscaleDeveloped by Dr. Joyce Black
M1131N 11.09
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