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Dashboard
Curriculum
Current Course
Concordance
Topics
Encyclopedia
Pharmaceuticals
Presentations
Videos
Case Studies
Clinical Judgment
Clinical Skills
Tools
Journal

Assessment Tool: Braden Scale

Rate each of the six subscales based on the patient's current status. Lower total scores indicate higher pressure injury risk and guide prevention protocol selection.

Braden Scale for Predicting Pressure Injury Risk

Six subscales scored 1–4 (Friction and Shear 1–3); total 6–23. Lower scores indicate higher risk. Developed by Braden and Bergstrom (1987).

Risk thresholds

19–23

No risk

15–18

At risk

13–14

Moderate risk

≤ 12

High / very high risk

Sensory Perception

Ability to respond meaningfully to pressure-related discomfort

[1] Completely limited — No response to pain; limited ability to feel [2] Very limited — Responds only to pain; cannot communicate discomfort except by moaning [3] Slightly limited — Responds to verbal commands but cannot always communicate discomfort [4] No impairment — Responds to verbal commands; no sensory deficit

Moisture

Degree to which skin is exposed to moisture

[1] Constantly moist — Skin kept moist almost constantly by perspiration, urine, etc. [2] Very moist — Skin is often but not always moist; linen changed at least once per shift [3] Occasionally moist — Skin occasionally moist; requires extra linen change about once a day [4] Rarely moist — Skin is usually dry; linen changed on routine intervals

Activity

Degree of physical activity

[1] Bedfast — Confined to bed [2] Chairfast — Ability to walk severely limited; cannot bear own weight [3] Walks occasionally — During day but for very short distances [4] Walks frequently — Outside the room at least twice a day

Mobility

Ability to change and control body position

[1] Completely immobile — Does not make even slight changes in body or extremity position [2] Very limited — Makes occasional slight changes; cannot make frequent or significant changes [3] Slightly limited — Makes frequent slight changes in body or extremity position independently [4] No limitations — Makes major and frequent changes in position without assistance

Nutrition

Usual food intake pattern

[1] Very poor — Never eats a complete meal; rarely eats more than ⅓ of food offered; receives inadequate nutrition [2] Probably inadequate — Rarely eats a complete meal; generally eats about ½ of food offered; may receive suboptimal nutrition via tube [3] Adequate — Eats more than half of most meals; eats 4 servings protein per day; occasionally refuses a meal [4] Excellent — Eats most of every meal; never refuses a meal; usually eats total of 4 or more servings of protein per day

Friction and Shear

Friction occurs when skin moves against support surfaces; shear occurs when skeleton slides

[1] Problem — Requires moderate to maximum assistance in moving; frequent repositioning needed; skin slides against sheets [2] Potential problem — Moves feebly or requires minimum assistance; skin probably slides against sheets to some extent [3] No apparent problem — Moves in bed and in chair independently and has sufficient muscle strength to lift up completely

Result

Score: 0/23

Risk level:

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