10.5 Braden Scale
Several factors place a patient at risk for developing a pressure injury, in addition to shear and friction. These factors include decreased sensory perception, increased moisture, decreased activity, impaired mobility, and inadequate nutrition. The Braden Scale is a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient’s risk for developing pressure injuries. See Figure 10.21[1] for an image of a Braden Scale. Risk factors are rated on a scale from 1 to 4, with 1 being “completely limited” and 4 being “no impairment.” The scores from the six categories are added, and the total score indicates a patient’s risk for developing a pressure injury based on these ranges:
- Mild risk: 15-18
- Moderate risk: 13-14
- High risk: 10-12
- Severe risk: less than 9
How to Score the Braden Scale
Each risk factor on the Braden Scale is rated from 1 to 4 based on the patient’s assessment findings. When using the Braden Scale, start with the first category and review each description listed across the row for each of the ratings from 1 to 4, and choose the one that best describes the patient’s current status. Continue this process for all rows. Add all six numbers to determine a total score, and then use the total score to determine if the patient is at mild, moderate, high, or severe risk for developing a pressure injury. The lower the score, the higher the risk of developing a pressure injury. Additionally, customized nursing interventions are implemented based on the rating in each category. The higher the score, the more aggressive actions are taken to prevent or heal a pressure injury. Descriptions of the ratings from 1-4 for each risk factor, along with targeted interventions for each rating, are further described in the following subsections.
Sensory Perception
The sensory perception risk factor is defined as the ability to respond meaningfully to pressure-related discomfort. If a patient is unable to feel pressure-related discomfort and respond to it appropriately by moving or reporting pain, they are at high risk of developing a pressure injury. This risk category describes two different issues that affect sensory perception. The first description refers to the patient’s level of consciousness, and the second description refers to the patient’s ability to feel cutaneous sensation. See Table 10.5a for a description of each level of risk from 1-4 with associated interventions for each level.[2]
Table 10.5a Descriptions and Interventions by Level of Risk for Sensory Perception
| Assessment Category | Rating Description | Interventions |
|---|---|---|
| Sensory Perception | 4–No Impairment
Responds to verbal commands. Has no sensory deficit that would limit ability to feel or voice pain or discomfort. |
|
| Sensory Perception | 3–Slightly Limited
Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR Has some sensory impairment that limits ability to feel pain or discomfort in 1 or 2 extremities. |
|
| Sensory Perception | 2–Very Limited
Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness. OR Has a sensory impairment that limits the ability to feel pain or discomfort over half of the body. |
All interventions mentioned in 3–Slightly Limited plus:
|
| Sensory Perception | 1–Completely Limited
Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation. OR Limited ability to feel pain over most of the body. |
All interventions mentioned in 2–Very Limited plus:
|
Moisture
The moisture risk factor is defined as the degree to which skin is exposed to moisture. Prolonged exposure to moisture increases the probability of skin breakdown. Moisture can come from several sources, such as perspiration, urine incontinence, stool incontinence, or wound drainage. Frequent surveillance, removal of wet or soiled linens, and use of protective skin barriers greatly reduce this risk factor. See Table 10.5b for specific interventions for each level of risk.[3]
Table 10.5b Interventions by Level of Risk for Moisture
| Rating Description | Interventions | |
|---|---|---|
| Moisture
|
4–Rarely Moist
Skin is usually dry; linen only requires changing at routine intervals. |
|
| Moisture
|
3–Occasionally Moist
Skin is occasionally moist, requiring an extra linen change approximately once per day. |
All interventions mentioned in 4–Rarely Moist plus:
|
| Moisture
|
2–Often Moist
Skin is often but not always moist. Linen must be changed at least once per shift. |
All interventions mentioned in 3–Occasionally Moist plus:
|
| Moisture
|
1–Constantly Moist
Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time the patient is moved or turned. |
All interventions mentioned in 2–Often Moist plus:
|
Activity
The activity risk factor is defined as the degree of physical activity. For example, walking or moving from a bed to a chair reduces a patient’s risk of developing a pressure injury by redistributing pressure points and increasing blood and oxygen flow to areas at risk.
Level of activity is defined by how frequently the patient is able to get out of bed, move into a chair, or ambulate with or without help. See Table 10.5c for a description of each level of risk from 1-4 with associated interventions for each.[4]
Table 10.5c Descriptions and Interventions by Level of Risk for Activity[5]
| Assessment Category | Rating Description | Interventions |
|---|---|---|
| Activity
|
4–Walks Frequently
Walks outside the room at least twice a day and inside the room at least once every two hours during waking hours. |
|
| Activity
|
3–Walks Occasionally
Walks occasionally during the day, but for very short distances, with or without assistance. Spends the majority of each shift in bed or chair. |
|
| Activity
|
2–Chair fast
Ability to walk is severely limited or nonexistent. Cannot bear their own weight and/or must be assisted into chair or wheelchair. |
|
| Activity
|
1–Bedfast
Confined to bed. |
|
Mobility
The mobility risk factor is defined as the patient’s ability to change or control their body position. For example, healthy people frequently change body position by rolling over in bed, shifting weight in a chair after sitting too long, or by moving their extremities. However, tissue damage will occur if a patient is unable to reposition on their own power unless caregivers frequently change their position. See Table 10.5d for interventions for each level of risk from 1-4.[6]
Table 10.5d Interventions by Level of Risk for Mobility[7]
| Assessment Category | Rating Description | Interventions |
|---|---|---|
| Mobility
|
4–No Limitations
Makes major and frequent changes in position without assistance. |
|
| Mobility
|
3–Slightly Limited
Makes frequent though slight changes in body or extremity position independently. |
|
| Mobility
|
2–Very Limited
Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. |
|
| Mobility
|
1-Completely Immobile
Does not make even slight changes in body or extremity position without assistance. |
Same interventions as for 2–Very Limited |
Nutrition
Adequate nutrition and fluid intake are vital for maintaining healthy skin. Protein intake, in particular, is very important for healthy skin and wound healing. The nutrition risk factor is defined by two categories of descriptions. The first category measures the amount and type of oral intake. The second category is used for patients receiving tube feeding, total parenteral nutrition (TPN), or are prescribed clear liquid diets or nothing by mouth (NPO). See Table 10.5e for interventions for each level of risk from 1-4.[8]
Table 10.5e Interventions by Level of Risk for Nutrition[9]
| Assessment Category | Rating Description | Interventions |
|---|---|---|
| Nutrition
|
4–Excellent
Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation. |
|
| Nutrition
|
3–Adequate
Eats over half of most meals. Eats a total of 4 servings of protein (meat and dairy products) each day. Occasionally refuses a meal, but will take a supplement if offered OR Is on a tube feeding or TPN regimen that most likely meets most of nutritional needs |
|
| Nutrition
|
2–Probably Inadequate
Rarely eats a complete meal and generally eats only about half of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dairy supplement OR Receives less than optimum amount of liquid diet or tube feeding. |
All interventions mentioned in 3–Adequate plus:
|
| Nutrition
|
1–Very Poor
Never eats a complete meal. Rarely eats more than one third of any food offered. Eats two servings of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR Is NPO and/or maintained on clear liquids or IV for more than 5 days. |
All interventions mentioned in 2–Probably Inadequate plus:
|
Friction/Shear
Friction and shear are significant risk factors for producing pressure injuries. This category only has three ratings, unlike the other categories that have four ratings, and is rated by whether the patient has a problem, potential problem, or no apparent problem in this area. See Table 10.5f for interventions for each level of risk.[10]
Table 10.5f Descriptions and Interventions by Level of Risk for Friction/Shear[11]
| Assessment Category | Rating Description | Interventions |
|---|---|---|
| Friction/Shear
|
3–No Apparent Problem
Moves in bed and chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times. |
Keep bed linens clean, dry, and wrinkle free. |
| Friction/Shear
|
2–Potential Problem
Moves feebly or requires minimal assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains a relatively good position in a chair or bed most of the time but occasionally slides down. |
All interventions mentioned in 3–No Apparent Problem plus:
|
| Friction/Shear
|
1–Problem
Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction. |
All interventions mentioned in 2–Potential Problem plus:
|
Team Member Roles to Prevent Pressure Injuries
Each member of the health care team has an important role in preventing the development of pressure injuries in at-risk patients. A registered nurse can delegate many interventions for preventing and treating a pressure injury to a licensed practical nurse (LPN) or to unlicensed assistive personnel such as a certified nursing assistant (CNA). See Table 10.5g for an explanation of the role of the RN in preventing pressure injuries, as well as tasks that can be delegated to LPNs and CNAs.
Table 10.5g Team Member Roles in Preventing Pressure Injuries[12]
| Role | Tasks |
|---|---|
| RN |
|
| LPN |
|
| CNA |
|
- This work is derivative of the "Braden Scale" by Prevention Plus. Used under Fair Use. Access for free at https://www.in.gov/core/results.html?collection=global-collection&profile=_default&query=braden+scale ↵
- Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.htm ↵
- Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.htm ↵
- Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.htm ↵
- Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.htm ↵
- Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.htm ↵
- Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.htm ↵
- Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.htm ↵
- Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.htm ↵
- Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.htm ↵
- Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.htm ↵
- Agency for Healthcare Research and Quality. (2014). Preventing pressure ulcers in hospitals. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.htm ↵
A standardized assessment tool used to assess and document a patient’s risk factors for developing pressure injuries.