Braden Scale & Risk Assessment
Key Takeaways
- The Braden Scale evaluates 6 subscales: Sensory Perception, Moisture, Activity, Mobility, Nutrition (all scored 1-4), and Friction & Shear (scored 1-3).
- Total score ranges from 6 to 23; lower scores indicate higher pressure injury risk.
- Risk categories: Mild Risk (15-18), Moderate Risk (13-14), High Risk (10-12), Very High Risk (<=9).
- Sensory/Mobility deficits require q2h bed turning with 30-degree lateral tilt, chair weight shifts q15min, and heel floating.
- Friction & Shear deficits require keeping head of bed elevation <= 30 degrees and using friction-reducing slide sheets for transfers.
Last updated: July 2026
Braden Scale & Risk Assessment
Identifying patients at risk for pressure injury development before tissue damage occurs is a cornerstone of clinical wound management. The Braden Scale for Predicting Pressure Sore Risk (Bergstrom & Braden, 1987) is the most extensively validated, widely implemented risk assessment tool across acute, post-acute, and long-term care settings. The ABWM Certified Wound Care Associate (CWCA) candidate must know every subscale, its exact numerical scoring range, overall risk cutoff thresholds, and how to translate specific subscale deficits into targeted, evidence-based preventive interventions.
Braden Scale Structure & Scoring Mechanics
The Braden Scale evaluates 6 distinct subscales reflecting the physiological and functional factors contributing to pressure injury formation.
1. Sensory Perception (1 to 4)
2. Moisture (1 to 4)
3. Activity (1 to 4)
4. Mobility (1 to 4)
5. Nutrition (1 to 4)
6. Friction & Shear (1 to 3) <-- *CRITICAL EXAM TRAP: Range is 1-3!*
Total Score Range
- Minimum Score: 6 (reflects maximum impairment / highest possible risk)
- Maximum Score: 23 (reflects no impairment / lowest possible risk)
- Inverse Relationship: Lower total scores indicate HIGHER risk for pressure injury development.
Comprehensive Subscale Scoring Reference
| Subscale | Score 1 | Score 2 | Score 3 | Score 4 |
|---|---|---|---|---|
| 1. Sensory Perception (Ability to respond meaningfully to pressure discomfort) | Completely Limited: Unresponsive to painful stimuli OR limited ability to feel pain over most body surface. | Very Limited: Responds only to painful stimuli; cannot communicate discomfort except by moaning/restlessness. | Slightly Limited: Responds to verbal commands; cannot always communicate discomfort or need to be turned. | No Impairment: Responds to verbal commands; full sensory perception and ability to feel/report pain. |
| 2. Moisture (Degree to which skin is exposed to moisture) | Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, etc. | Very Moist: Skin is often but not always moist; linen changed at least once per shift. | Occasionally Moist: Skin is occasionally moist, requiring extra linen change ~once per day. | Rarely Moist: Skin is usually dry; linen changed only at routine intervals. |
| 3. Activity (Degree of physical activity) | Bedfast: Confined to bed continuously. | Chairfast: Ability to walk severely limited or non-existent; cannot bear weight. | Walks Occasionally: Walks occasionally during day, short distances with/without help. | Walks Frequently: Walks outside room at least twice daily and inside at least once q2h. |
| 4. Mobility (Ability to change/control body position) | Completely Immobile: Does not make even slight changes in position without assistance. | Very Limited: Makes occasional slight changes in position; unable to make frequent/major changes. | Slightly Limited: Makes frequent though slight changes in position independently. | No Limitation: Makes major and frequent changes in position without assistance. |
| 5. Nutrition (Usual food intake pattern) | Very Poor: Never eats complete meal; rarely eats >1/3 food; NPO/IV fluids >5 days. | Probably Inadequate: Rarely eats complete meal; generally eats ~1/2 food offered. | Adequate: Eats over half of most meals; occasionally refuses meal but takes supplement. | Excellent: Eats most of every meal; never refuses; eats 4+ servings protein daily. |
| 6. Friction & Shear (Sliding & friction forces during movement) | Problem: Requires moderate to max assist in moving; complete lifting without sliding impossible. | Potential Problem: Moves feebly or requires min assist; skin slides to some extent against sheets. | No Apparent Problem: Moves in bed and chair independently; sufficient strength to lift completely clear. | N/A (Subscale score caps at 3) |
Risk Stratification Categories
Clinical risk protocol triggers are based on total Braden Scale scores:
\textbf{Mild Risk:} & \quad 15 - 18 \\ \textbf{Moderate Risk:} & \quad 13 - 14 \\ \textbf{High Risk:} & \quad 10 - 12 \\ \textbf{Very High Risk (Severe):} & \quad \le 9 \end{aligned}$$ *Assessment Frequency Standard*: Braden scoring must be performed upon admission, daily in acute care, every 48 hours in critical care, weekly for 4 weeks in long-term care (then monthly), and immediately following any significant change in patient status. --- ## Targeted Clinical Prevention Protocols by Subscale Deficit Effective prevention requires matching clinical interventions directly to specific low subscale scores (scores ≤2). ``` BRADEN SUBSCALE DEFICIT INTERVENTION MAP [Sensory / Mobility <= 2] --> q2h Bed Turning / 30-deg Tilt / Float Heels / Support Surfaces [Moisture <= 2] --> pH-Balanced Cleansers / Barrier Creams / Breathable Pads [Nutrition <= 2] --> RDN Consult / High Protein 1.2-1.5g/kg / ONS / Supplements [Friction & Shear <= 2] --> HOB Elevation <= 30 deg / Slide Sheets / Trapeze Bar ``` ### 1. Interventions for Low Sensory Perception & Mobility (Scores ≤ 2) - **Repositioning Schedules**: - Bedbound patients: Reposition at least **every 2 hours**. Utilize a **30-degree tilted side-lying position** (30-degree lateral incline using wedges behind the back) to avoid direct pressure on the greater trochanters and sacrum. - Chairbound patients: Shift weight **every 15 minutes** if capable independently; reposition at least **every 1 hour** if dependent. - **Heel Elevation**: "Float" heels completely off the mattress by placing pillows under the full length of the lower legs (calves) or using specialized rigid heel suspension boots. - **Support Surfaces**: Place high-specification reactive foam mattresses for mild/moderate risk; active alternating-pressure or low-air-loss dynamic surfaces for high/very high risk. ### 2. Interventions for Low Moisture (Scores ≤ 2) - **Skin Hygiene**: Cleanse skin immediately following each incontinence episode using a pH-balanced, non-rinse perineal cleanser. Avoid harsh alkaline bar soaps. - **Skin Protection**: Apply dimethicone-based, zinc oxide, or petrolatum barrier ointments to perineal, perianal, and gluteal skin after cleansing. - **Underpad Protocol**: Utilize single, high-absorbency, breathable underpads. *Never stack multiple underpads*, which traps heat, increases humidity, and negates support surface performance. ### 3. Interventions for Low Nutrition (Scores ≤ 2) - **Dietitian Consultation**: Request a formal Registered Dietitian Nutritionist (RDN) assessment within 24 hours. - **Nutritional Targets**: Provide **30 to 35 kcal/kg/day** caloric intake and **1.2 to 1.5 g/kg/day** protein intake (unless contraindicated by severe renal failure). - **Supplements**: Provide oral nutritional supplements (ONS) enriched with protein, arginine, zinc, and Vitamin C between meals. ### 4. Interventions for Low Friction & Shear (Scores ≤ 2) - **Head of Bed (HOB) Elevation**: Maintain HOB elevation at **≤ 30 degrees** (unless contraindicated by cardiac, respiratory, or enteral feeding protocols) to prevent the pelvis from sliding forward and shearing sacral tissue. - **Transfer Techniques**: Utilize friction-reducing slide sheets, transfer boards, or mechanical ceiling lifts for all positioning changes. **NEVER drag or pull a patient across bed linens**. - **Assistive Equipment**: Install an overhead trapeze bar to enable patient self-positioning.Test Your Knowledge
What is the maximum achievable score on the Friction & Shear subscale of the Braden Scale?
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Test Your Knowledge
A clinical assessment yields a total Braden Scale score of 11 for a hospitalized post-surgical patient. Into which risk category does this total score place the patient?
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Test Your Knowledge
A patient scores a 1 (Problem) on the Friction & Shear subscale of the Braden Scale. Which of the following clinical nursing interventions directly targets this specific deficit?
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