Chart — Wound Care
Braden Scale for Pressure Injury Risk
The Braden Scale is the most widely validated tool for predicting pressure injury risk in hospitalized patients. It assesses six subscales related to the etiology of pressure injuries — lower scores indicate higher risk.
Source: Braden Scale — Barbara Braden, PhD, RN & Nancy Bergstrom, PhD, RN, FAAN (1987)
Educational use only. The Braden Scale is a validated clinical tool. Apply scores in context with full clinical assessment and your facility's pressure injury prevention protocol. Risk thresholds may vary by institution. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Scoring Overview
| Subscale | Score Range | What It Measures |
|---|---|---|
| Sensory Perception | 1 – 4 | Ability to feel and respond to pressure-related discomfort |
| Moisture | 1 – 4 | Degree to which skin is exposed to moisture |
| Activity | 1 – 4 | Degree of physical activity |
| Mobility | 1 – 4 | Ability to change and control body position |
| Nutrition | 1 – 4 | Usual food intake pattern |
| Friction and Shear | 1 – 3 | Forces that damage skin and underlying tissue during movement |
Total score range: 6 (highest risk) to 23 (lowest risk). Lower = more risk.
Subscale Scoring Detail
1. Sensory Perception
1–4 pts| Score | Label | Description |
|---|---|---|
| 1 | Completely Limited | Unresponsive (does not moan, flinch, or grasp) to painful stimuli, or diminished ability to feel pain over most of body surface |
| 2 | Very Limited | Responds only to painful stimuli; cannot communicate discomfort except by moaning or restlessness; OR sensory impairment over half of body |
| 3 | Slightly Limited | Responds to verbal commands but cannot always communicate discomfort; OR has some sensory impairment limiting pain/discomfort in 1–2 extremities |
| 4 | No Impairment | Responds to verbal commands; has no sensory deficit that limits ability to feel or voice pain or discomfort |
2. Moisture
1–4 pts| Score | Label | Description |
|---|---|---|
| 1 | Constantly Moist | Skin is kept moist almost constantly by perspiration, urine, or other fluids; dampness detected every time patient is moved or turned |
| 2 | Often Moist | Skin is often but not always moist; linen must be changed at least once per 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 only requires changing at routine intervals |
3. Activity
1–4 pts| Score | Label | Description |
|---|---|---|
| 1 | Bedfast | Confined to bed |
| 2 | Chairfast | Ability to walk severely limited or nonexistent; cannot bear own weight; must be assisted into chair or wheelchair |
| 3 | Walks Occasionally | Walks occasionally during day but for very short distances; spends majority of shift in bed or chair |
| 4 | Walks Frequently | Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours |
4. Mobility
1–4 pts| Score | Label | Description |
|---|---|---|
| 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
1–4 pts| Score | Label | Description |
|---|---|---|
| 1 | Very Poor | Never eats a complete meal; rarely eats more than 1/3 of any food offered; eats 2 or fewer protein servings/day; takes fluids poorly; does not take a liquid dietary supplement |
| 2 | Probably Inadequate | Rarely eats a complete meal; generally eats about half of any food offered; protein intake includes only 3 servings/day; occasionally takes dietary supplement |
| 3 | Adequate | Eats over half of most meals; eats total of 4 protein servings/day; occasionally refuses a meal but usually takes supplement if offered; or is on tube feeding/TPN providing most nutritional needs |
| 4 | Excellent | Eats most of every meal; never refuses a meal; usually eats 4 or more protein servings/day; occasionally eats between meals; does not require supplementation |
6. Friction and Shear
1–3 pts| Score | Label | Description |
|---|---|---|
| 1 | Problem | Requires moderate to maximum assistance with moving; complete lifting without sliding against sheets is impossible; frequently slides down in bed or chair; spasticity, contractures, or agitation causes constant friction |
| 2 | Potential Problem | Moves feebly or requires minimum assistance; during a move, skin probably slides against sheets, chair, restraints, or other devices; maintains relatively good position in chair or bed most of the time but occasionally slides down |
| 3 | No Apparent Problem | Moves in bed and in chair independently; has sufficient muscle strength to lift up completely during move; maintains good position in bed or chair at all times |
Total Score Interpretation
| Total Score | Risk Level | Recommended Response |
|---|---|---|
| ≥ 19 | No Risk | Routine skin assessment; standard care; patient education |
| 15 – 18 | Mild Risk | Preventive interventions; repositioning schedule; skin care; nutrition monitoring |
| 13 – 14 | Moderate Risk | Formal prevention plan; consider pressure-redistributing support surface; moisture management; dietary consult |
| 10 – 12 | High Risk | Aggressive repositioning schedule; active support surface; comprehensive skin and nutrition plan; wound care consultation |
| ≤ 9 | Very High Risk | Maximum interventions; specialty support surface; frequent skin inspection; dietitian and wound care specialist involvement |
Total score range: 6–23. Score ≤ 18 indicates at-risk status by many institutional protocols. Reassess on admission, at condition change, and at transfer of care.
Related Resources
Standards & sources
Fact-checked Jun 21, 2026This page is written to align with Braden Scale — Braden & Bergstrom. It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →