Braden Scale Risk Assessment
Validated Tool for Predicting Pressure Injury Risk
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Braden Scale Assessment
Rate the patient on each of the 6 subscales below. Select the description that best matches the patient's current status.
Understanding Pressure Injuries
Pressure injuries (formerly called pressure ulcers or bedsores) are localized damage to the skin and underlying tissue, usually occurring over a bony prominence as a result of prolonged pressure, or pressure in combination with shear.
Key Risk Factors
- Immobility: The single greatest risk factor. Patients who cannot reposition themselves are at highest risk
- Poor nutrition: Inadequate protein, calories, and micronutrients impair skin integrity and wound healing
- Moisture: Excessive skin moisture from incontinence, perspiration, or wound drainage macerates the skin
- Sensory impairment: Patients who cannot feel pain may not shift position to relieve pressure
- Advanced age: Aging skin becomes thinner, less elastic, and more vulnerable to injury
- Comorbidities: Diabetes, vascular disease, and conditions affecting tissue perfusion increase risk
Prevalence
Pressure injuries affect approximately 2.5 million patients annually in the United States. In acute care settings, prevalence ranges from 5% to 15%. In long-term care facilities, prevalence can reach 25% or higher. The annual cost of treating pressure injuries in the US exceeds $26 billion.
The 6 Braden Subscales Explained
Sensory Perception (1-4)
Evaluates the patient's ability to respond meaningfully to pressure-related discomfort. Patients with impaired sensation (due to spinal cord injury, neuropathy, sedation, or altered consciousness) cannot feel the need to shift position and are at increased risk.
Moisture (1-4)
Assesses the degree to which skin is exposed to moisture. Excessive moisture from incontinence, perspiration, or wound drainage macerates the skin, making it more susceptible to breakdown. A score of 1 indicates the skin is almost constantly moist.
Activity (1-4)
Measures the patient's degree of physical activity. Patients confined to bed or chair have sustained pressure on tissue overlying bony prominences. Walking, even occasionally, significantly reduces risk.
Mobility (1-4)
Evaluates the ability to change and control body position independently. Even patients in bed can reduce pressure if they can shift their weight. Complete immobility represents the highest risk.
Nutrition (1-4)
Assesses usual food intake pattern. Adequate nutrition, particularly protein intake, is essential for maintaining skin integrity and supporting wound healing. Patients who are NPO, on clear liquids, or eating poorly are at increased risk.
Friction & Shear (1-3)
This subscale has only 3 levels (not 4). Friction occurs when the skin moves across a surface. Shear occurs when the skeleton slides against tissue (such as when a patient slides down in bed). Both can damage blood vessels and tissue.
Evidence-Based Prevention Strategies
Repositioning
- Turn bed-bound patients at least every 2 hours
- Use a 30-degree lateral turn to offload the sacrum and trochanters
- Reposition chair-bound patients every hour; shift weight every 15 minutes
- Use pillows or foam wedges to keep bony prominences from direct contact
- Avoid positioning directly on the trochanter; use a 30-degree tilted position
Support Surfaces
- Use pressure-redistributing mattresses for at-risk patients (reactive foam, alternating pressure, low-air-loss)
- Avoid ring-shaped cushions (donut pillows) as they concentrate pressure at the edges
- Consider specialty beds for patients with existing pressure injuries or very high risk
Skin Care
- Keep skin clean and dry; use pH-balanced cleansers
- Apply moisture barriers for patients with incontinence
- Inspect skin daily, paying attention to bony prominences
- Avoid massage over bony prominences or reddened areas
Nutrition
- Ensure adequate caloric and protein intake (1.25-1.5 g protein/kg/day for at-risk patients)
- Consult a registered dietitian for patients with nutritional deficits
- Consider supplements with vitamin C, zinc, and arginine for wound healing support
Pressure Injury Staging (NPUAP/EPUAP)
Stage 1: Non-blanchable Erythema
Intact skin with a localized area of non-blanchable erythema. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. In darkly pigmented skin, erythema may not be visible; look for color changes, temperature differences, or edema.
Stage 2: Partial-Thickness Skin Loss
Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or ruptured serum-filled blister. Should not be used to describe skin tears, tape burns, or moisture-associated skin damage.
Stage 3: Full-Thickness Skin Loss
Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth. May include undermining and tunneling. Depth varies by anatomic location.
Stage 4: Full-Thickness Tissue Loss
Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Depth varies by anatomic location.
Unstageable
Full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed. Until enough slough/eschar is removed to expose the base, the true depth cannot be determined.
Deep Tissue Pressure Injury
Persistent non-blanchable deep red, maroon, or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister.
Clinical Application of the Braden Scale
When to Assess
- Acute care: On admission and every 24-48 hours, or whenever the patient's condition changes
- Long-term care: On admission, weekly for 4 weeks, then quarterly and whenever condition changes
- Home health: On admission and at every visit for the first few weeks, then periodically
Score Interpretation
- 19-23: No significant risk - Continue routine prevention
- 15-18: Mild risk - Implement basic prevention protocol
- 13-14: Moderate risk - Implement enhanced prevention
- 10-12: High risk - Implement aggressive prevention
- 6-9: Severe risk - Maximum prevention measures required
Psychometric Properties
The Braden Scale has demonstrated good sensitivity (83-100%) and specificity (64-90%) across multiple validation studies. The tool has been validated in acute care, long-term care, and home health settings. Inter-rater reliability is highest when assessors receive standardized training.
Limitations
- Does not account for all risk factors (e.g., perfusion, diabetes, medications)
- Optimal cutoff score may vary by clinical setting and population
- Clinical judgment should supplement the scale, not be replaced by it
- Regular reassessment is essential as patient conditions change
Frequently Asked Questions
The Braden Scale for Predicting Pressure Sore Risk was developed in 1987 by Barbara Braden and Nancy Bergstrom. It is the most widely used validated tool for assessing pressure injury risk in clinical settings. The scale evaluates six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear, producing a total score from 6 (highest risk) to 23 (lowest risk).
Unlike most scales where higher scores mean worse outcomes, the Braden Scale is inverse: lower scores indicate higher risk. Scores of 19-23 indicate no significant risk, 15-18 mild risk, 13-14 moderate risk, 10-12 high risk, and 6-9 severe risk. Most clinical guidelines use a cutoff score of 18 or below to initiate prevention protocols.
Assessment frequency varies by setting: In acute care, assess on admission and every 24-48 hours. In ICU settings, every 24 hours. In long-term care, on admission, weekly for the first month, then quarterly. In home health, at every visit initially. Always reassess when the patient's condition significantly changes (e.g., after surgery, new diagnosis, change in mobility).
The Friction & Shear subscale uses a 1-3 scoring system rather than 1-4 like the other five subscales. This is because Bergstrom and Braden found that friction and shear are more difficult to assess with fine distinctions. The three levels (Problem, Potential Problem, No Apparent Problem) were determined to be the most reliable and clinically meaningful divisions. This means the maximum total Braden score is 23, not 24.
The Braden Scale was developed and validated primarily for adult patients. It has been validated in acute care, long-term care, and home health settings. For pediatric patients, the Braden Q Scale (a modified version) should be used instead. The scale may need different cutoff scores for specific populations, such as ICU patients or patients in operating rooms.
Prevention should be matched to risk level: For mild risk (15-18), implement a turning schedule, pressure-redistributing surface, and nutritional assessment. For moderate risk (13-14), add more frequent repositioning, consider a specialty mattress, and begin a nutrition support protocol. For high risk (10-12), implement aggressive interventions including specialty surfaces, 2-hour turning, moisture management, and dietitian consultation. For severe risk (6-9), maximum interventions are required including advanced support surfaces, strict repositioning, intensive nutritional support, and close monitoring.
Yes, the Braden Scale has demonstrated good predictive validity across numerous studies. Sensitivity ranges from 83-100% and specificity from 64-90%, depending on the cutoff score and population studied. A cutoff of 18 or below provides the best balance of sensitivity and specificity in most settings. However, the scale should be used in conjunction with clinical judgment, not as a standalone predictor.
⚠ Medical Disclaimer
This Braden Scale calculator is intended for educational and clinical reference purposes. It should be used by or under the guidance of qualified healthcare professionals. It does not replace comprehensive clinical assessment, professional nursing judgment, or individualized care planning. Always follow your facility's pressure injury prevention protocols and consult the interdisciplinary care team.
Clinical References
- Bergstrom, N., Braden, B. J., Laguzza, A., & Holman, V. (1987). The Braden Scale for Predicting Pressure Sore Risk. Nursing Research, 36(4), 205-210.
- Braden, B. J., & Bergstrom, N. (1994). Predictive Validity of the Braden Scale for Pressure Sore Risk in a Nursing Home Population. Research in Nursing & Health, 17(6), 459-470.
- European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, & Pan Pacific Pressure Injury Alliance (2019). Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. EPUAP/NPIAP/PPPIA.
- Agency for Healthcare Research and Quality (AHRQ). (2014). Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care.
- Centers for Medicare & Medicaid Services (CMS). Pressure Ulcer/Injury Quality Measures.