Braden Scale
The Braden Scale is a standardized clinical tool used to assess a patient's risk for developing pressure injuries (bedsores). It evaluates six risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear, with scores ranging from 6 (highest risk) to 23 (lowest risk).
Exam Tip
Braden Scale: lower score = higher pressure injury risk. Six factors: sensory perception, moisture, activity, mobility, nutrition, friction/shear. CNA responsibilities: reposition every 2 hours, keep skin clean and dry, report redness or skin breakdown immediately.
What Is the Braden Scale?
The Braden Scale is the most widely used pressure injury risk assessment tool in healthcare. It was developed by Barbara Braden and Nancy Bergstrom in 1987. CNAs play a critical role in observing and reporting the factors measured by the Braden Scale, even though the RN typically completes the formal assessment.
Six Subscales of the Braden Scale
| Subscale | What It Measures | Score Range |
|---|---|---|
| Sensory Perception | Ability to feel and respond to pressure-related discomfort | 1-4 |
| Moisture | Degree of skin exposure to moisture (sweat, urine, stool) | 1-4 |
| Activity | Degree of physical activity (bedfast, chairfast, walks) | 1-4 |
| Mobility | Ability to change and control body position | 1-4 |
| Nutrition | Usual food intake pattern and adequacy | 1-4 |
| Friction and Shear | Degree of sliding against surfaces during repositioning | 1-3 |
Risk Categories
| Total Score | Risk Level | Interventions |
|---|---|---|
| 19-23 | No risk | Standard prevention |
| 15-18 | Mild risk | Turning schedule, skin assessment |
| 13-14 | Moderate risk | Pressure-relieving mattress, nutrition consult |
| 10-12 | High risk | Frequent repositioning (every 2 hours), barrier cream |
| 9 or below | Very high risk | All above plus specialty bed, wound care consult |
CNA Role in Pressure Injury Prevention
- Reposition patients every 2 hours (or as care plan directs)
- Keep skin clean and dry (prompt incontinence care)
- Report skin changes immediately (redness, warmth, open areas)
- Ensure adequate nutrition and hydration (report poor intake)
- Use proper lifting techniques to avoid friction and shear
- Check bony prominences during care (heels, sacrum, elbows, shoulders)
Exam Alert
While CNAs do not formally score the Braden Scale, you must understand the risk factors it measures and your role in prevention. Know that repositioning every 2 hours is the gold standard, that moisture (incontinence) greatly increases risk, and that reporting skin changes early is critical. A lower Braden score means HIGHER risk.
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Related Terms
Decubitus Ulcer (Pressure Injury)
A decubitus ulcer (also called a pressure injury, pressure sore, or bedsore) is localized damage to the skin and underlying tissue caused by prolonged pressure, friction, or shear, typically over bony prominences. Pressure injuries are classified in stages from Stage 1 (intact skin with non-blanchable redness) to Stage 4 (full-thickness tissue loss exposing bone, muscle, or tendon).
Activities of Daily Living (ADLs)
Activities of Daily Living (ADLs) are the fundamental self-care tasks that individuals perform daily, including bathing, dressing, eating, toileting, transferring (mobility), and continence. Assessing ADLs helps nurses determine a patient's functional status and care needs.
Body Mechanics
Body mechanics refers to the coordinated use of body position, movement, and alignment to prevent injury during patient care activities such as lifting, transferring, and repositioning. Proper body mechanics protect both the nurse and the patient from musculoskeletal injury.
Intake and Output (I&O)
Intake and Output (I&O) is a nursing measurement that tracks all fluids entering (intake) and leaving (output) a patient's body over a specified period, typically 24 hours. Accurate I&O monitoring is essential for assessing fluid balance, kidney function, and hydration status.
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