When over 2.5 million people are affected by pressure injuries each year, intervention and prevention are key.

Pressure injuries and their treatment are estimated to cost 11 billion dollars annually. While some pressure injuries develop despite caregivers’ best efforts, they are largely preventable. But once pressure injuries develop, they can be prevented from ongoing deterioration and infection.

The Braden Scale is an evidence-based tool that has been widely adopted in hospitals and other inpatient facilities throughout the country. It is highly effective in predicting the risk for pressure injuries, especially hospital-acquired pressure injuries (HAPI) and tissue tolerance. Let’s take a closer look at the structure of this scale and what each category measures.

What is a Braden Scale?

The Braden Scale is the most frequently used pressure injury risk assessment tool in the United States, according to the National Institute of Health (NIH). Created in 1987 by nurses, Barbara Braden and Nancy Bergstrom, the Braden Scale helps determine the risk of a patient developing a pressure injury.

The scale is divided into six assessment categories. Each category is given a score of one to four. These six scores are then added together to give the patient’s overall Braden score. The lower the Braden score, the higher the risk of skin breakdown.

Braden Scale assessment: Defined

Clinicians use the Braden Scale to evaluate a patient’s risk for developing pressure injuries. Understanding the following Braden Scale categories as well as how to use it effectively is crucial for providing optimal care.

1. Sensory perception

Sensory perception assesses a patient’s ability to feel discomfort or pain. This is important for skin health as it allows a patient to move the painful area or communicate their discomfort. Partial or total paralysis and varying degrees of neuropathy are also assessed in this category.

  • Completely limited: Score of 1
  • Very limited: Score of 2
  • Slightly limited: Score of 3
  • No impairment: Score of 4

2. Moisture

This risk factor evaluates a patient’s exposure to moisture. This could include drainage from a wound, urine, stool, fistula output, sweat, and lymphorrhagia. Prolonged exposure to moisture places skin at an increased risk for breakdown.

  • Constantly moist: Score of 1
  • Very moist: Score of 2
  • Occasionally moist: Score of 3
  • Rarely moist: Score of 4

3. Activity

Activity gauges a patient’s ability to reposition and move their body independently or with support of mobility aids like a walker or cane. This is important, as frequent position changes prevent ongoing pressure to body parts at risk for skin breakdown.

  • Bedfast: Score of 1
  • Chairfast: Score of 2
  • Walks occasionally: Score of 3
  • Walks frequently: Score of 4

4. Mobility

Mobility looks at a patient’s ability to independently change and control their body position while in bed or a chair. The inability to move the body or change one’s own body position increases the risk for skin breakdown.

  • Completely immobile: Score of 1
  • Very limited: Score of 2
  • Slightly immobile: Score of 3
  • No limitation: Score of 4

5. Nutrition

This risk factor assesses a patient’s nutritional status, including the type and amount of nutritional intake. This category not only assesses oral intake but also includes nutrition by alternate means such as tube feedings and total parenteral nutrition. It accounts for patients who eat only partial amounts of their meals or eat foods with minimal nutritional quality. Inadequate nutritional intake is a significant risk factor for skin breakdown, deterioration of existing wounds, and the body’s inability to heal a wound once developed.

  • Very poor: Score of 1
  • Probably inadequate: Score of 2
  • Adequate: Score of 3
  • Excellent: Score of 4

6. Friction and shear

Friction and shear measure a patient’s muscle strength and ability to maintain their positioning in bed or chair. It includes patients that slide down in bed and the degree of skin sliding against sheets during transfers or with agitation/restlessness.

  • Problem: Score of 1
  • Potential problem: Score of 2
  • No apparent problem: Score of 3

Braden Scale range next steps

Once the patient has been given a score in each of the six above categories, the total score is the patient’s overall Braden score.

  • 19–23 equals no risk
  • 15–18 equals mild risk
  • 13–14 equals moderate risk
  • 10–12 equals high risk
  • <9 equals severe risk

No risk: Patients are unlikely to develop skin breakdown. However, they should be monitored at routine intervals for changes in their status that may alter their Braden score and place them at risk for pressure injuries.

Mild risk: Patients may need education on skin hygiene, increasing physical activity, or supplementing a mildly deficient diet.

Moderate risk: Patients and their caregivers likely need education on proper nutrition for skin health, skin hygiene, proper body positioning, and repositioning intervals.

High risk:  Patients and their caregivers need more in-depth education on nutrition, skin health, proper body positioning in bed and while in chairs, as well as proper repositioning intervals. Extra equipment at home will likely be needed to help with transferring the patient safely and help decrease the risk of friction and shearing of the tissues.

Severe risk: Patients are at such high risk for skin breakdown, frequent monitoring will be essential. Frequent monitoring will detect pressure injuries sooner so proper treatment can begin and will also help prevent existing pressure injuries from worsening.

Final thoughts

The use of the Braden scale is not a one-and-done assessment. This tool should be used at routine intervals to reassess a patient’s risk for skin breakdown. Patients in any of the above categories should be monitored for pressure injury prevention and early detection.

By utilizing this tool, healthcare professionals can identify pressure injuries earlier and take necessary steps to prevent wounds from worsening, reduce the risk of infection, and make timely adjustments to the care plan. The Braden Scale is an essential instrument for the daily care of both hospital and long-term care patients.

Editor’s Note: This content was originally published in February 2022 and has been updated with new content.

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Tara Call Triplett, RN, WCC, CHFN

Tara Call Triplett has over 20 years of experience as a registered nurse and is the founder of Call to Health Communications. She is nationally certified in both wound care and heart failure. Triplett currently leads an amazing team of clinicians at an award winning outpatient wound care clinic. She has a passion for teaching and mentoring the next generation of wound care clinicians.

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