2.3 Pressure Injury Risk Assessment: Braden Scale Subscales & Scoring

Pressure Injury Risk Assessment: Braden Scale Subscales & Scoring

Pressure injury prevention depends on early identification of at-risk individuals using validated risk assessment tools. The Braden Scale for Predicting Pressure Sore Risk (developed by Barbara Braden and Nancy Bergstrom) is the most widely utilized and psychometrically validated instrument across acute, long-term, and community care environments. It synthesizes the major pathophysiological drivers of pressure injuries—specifically factors determining pressure duration/intensity (sensory perception, mobility, activity) and factors determining tissue tolerance (moisture, nutrition, friction/shear).

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The Six Braden Scale Subscales

The Braden Scale assesses six clinical subscales. Five subscales are scored from 1 (worst/highest impairment) to 4 (best/no impairment), while the Friction and Shear subscale is scored from 1 to 3.

1. Sensory Perception (Ability to respond meaningfully to pressure-related discomfort)

• 1 - Completely Limited: Unresponsive (does not moan, flinch, or grasp) to painful stimuli due to diminished consciousness or sedation, OR limited ability to feel pain over most body surface.
• 2 - Very Limited: Responds only to painful stimuli; cannot communicate discomfort except by moaning/restlessness, OR has sensory impairment over >50% of body.
• 3 - Slightly Limited: Responds to verbal commands, but cannot always communicate discomfort or need to be turned, OR has sensory impairment in 1 or 2 extremities.
• 4 - No Impairment: Responds to verbal commands; has no sensory deficit limiting ability to feel or voice pain/discomfort.

2. Moisture (Degree to which skin is exposed to moisture)

• 1 - Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, or drainage; detected every time patient is moved/turned.
• 2 - Very Moist: Skin is often but not always moist; linen must be changed at least once a shift.
• 3 - Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day.
• 4 - Rarely Moist: Skin is usually dry; linen changed only at routine intervals.

3. Activity (Degree of physical activity)

• 1 - Bedfast: Confined to bed.
• 2 - Chairfast: Ability to walk severely limited or non-existent; cannot support own weight and/or must be assisted into chair/wheelchair.
• 3 - Walks Occasionally: Walks occasionally during day, but for very short distances, with or without assistance; spends majority of shift in bed or chair.
• 4 - Walks Frequently: Walks outside room at least twice a day and inside room at least once every 2 hours during waking hours.

4. Mobility (Ability to change and control body position)

• 1 - Completely Immobile: Does not make even slight changes in body or extremity position without assistance.
• 2 - Very Limited: Makes occasional slight changes in body or extremity position, but unable to make frequent or significant changes independently.
• 3 - Slightly Limited: Makes frequent though slight changes in body or extremity position independently.
• 4 - No Limitation: Makes major and frequent changes in position without assistance.

5. Nutrition (Usual food intake pattern)

• 1 - Very Poor: Never eats a complete meal; rarely eats more than 1/3 of food offered; drinks liquid supplements poorly, OR is NPO/on clear liquids/IV for >5 days.
• 2 - Probably Inadequate: Rarely eats a complete meal and generally eats about 1/2 of food offered; receives less than optimum amount of liquid diet or tube feeding.
• 3 - Adequate: Eats over half of most meals; refuses a meal occasionally, but will usually take a supplement if offered, OR is on tube feeding/TPN meeting nutritional needs.
• 4 - Excellent: Eats most of every meal; never refuses food; usually eats a total of 4 or more servings of meat and dairy products.

6. Friction and Shear (Assesses physical sliding against sheets/surfaces)

• 1 - Problem: Requires moderate to maximum assistance in moving; complete lifting without sliding against sheets is impossible; frequently slides down in bed or chair.
• 2 - Potential Problem: Moves feebly or requires minimum assistance; during a move skin probably slides to some extent against sheets, chair, or restraints.
• 3 - No Apparent Problem: Moves in bed and chair independently and has sufficient muscle strength to lift completely clear of all surfaces during movement.

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Total Scoring & Risk Stratification Cutoffs

The total score is calculated by summing all 6 subscales. Total scores range from 6 (maximum risk) to 23 (no risk).

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Subscale-Driven Prevention Bundles

Effective prevention requires targeting individual subscale deficits rather than relying solely on the overall total score:

• Moisture Deficit (<= 2): Apply pH-balanced skin cleansers and dimethicone/zinc barrier ointments; utilize breathable, moisture-wicking underpads; establish an incontinence management protocol.
• Mobility/Activity Deficit (<= 2): Implement a strict 2-hour repositioning schedule in bed; perform 15-minute micro-shifts in chairs; place reactive high-specification foam or active alternating-pressure mattresses; float heels completely off the bed using pillows or heel-suspension boots.
• Friction/Shear Deficit (1 or 2): Maintain head of bed (HOB) elevation at or below 30° (unless contraindicated); use friction-reducing slide sheets or mechanical lift devices for patient transfers; apply protective transparent films or thin hydrocolloids to heels and elbows.
• Nutrition Deficit (<= 2): Request an immediate Registered Dietitian (RD) consult; initiate oral high-protein nutritional supplements (targeting 1.25 to 1.5 g/kg/day of protein); track daily calorie and meal intake.