Braden Scale
A risk assessment tool for pressure injury prevention
Definition
The Braden Scale is the most widely used validated tool for assessing a patient's risk of developing pressure injuries (decubitus ulcers). It assesses six factors on a numeric scale.
Six Categories
- Sensory perception (1 to 4): Ability to respond to pressure-related discomfort.
- Moisture (1 to 4): Degree of skin exposure to moisture.
- Activity (1 to 4): Degree of physical activity.
- Mobility (1 to 4): Ability to change body position.
- Nutrition (1 to 4): Usual food intake pattern.
- Friction and shear (1 to 3): Resistance to movement.
Risk Levels (Total Score)
- 19 to 23: Minimal to no risk
- 15 to 18: Mild risk
- 13 to 14: Moderate risk
- 10 to 12: High risk
- 9 or below: Very high risk
Nursing Interventions Based on Score
Lower scores warrant more aggressive prevention: frequent repositioning (every 2 hours), pressure-redistribution mattresses, heel floating, skin moisture management, nutrition consultation, and physical therapy.
Nursing Considerations
Perform Braden assessment on admission and at least daily (or per facility policy). Document interventions matched to the risk level. Reassess after changes in condition.
NCLEX Relevance
Braden Scale is referenced in many pressure injury prevention questions. Lower score = higher risk. Prevention is always preferable to treatment.