Braden Risk Assessment Scale

Instructions: Factors Further Increasing Risk

1. Assess patient’s risk to skin breakdown. Peripheral Vascular Disease, impaired circulation, vasoconstriction drugs, braces or stabilizing equipment,
2. To calculate a Braden Score, choose the appropriate score from each category and total them. diabetes, CHF, COPD, history of ulcers, preterm neonates, obesity/thin 30>BMI<19, Critical labs:
3. If a category score falls between two numbers, choose the lower score. prealbumin (reflects visceral protein stores) mild depletion = 10-15, moderate depletion = 5-10, severe
4. Calculate a Braden Score upon admission and every 24 hours afterward and document on the Patient Care Flow depletion less than 5.
Sheet.
5. If score is 18 or lower, initiate recommended interventions for each category. (See back side.)
Braden Braden Score: 1 Braden Score: 2 Braden Score: 3 Braden Score: 4
Category
Sensory Completely limited Very limited Slightly limited No limitation
Perception Unresponsive (does not moan, flinch or Responds only to painful stimuli; Responds to verbal commands but cannot always Responds to verbal commands.
Ability to grasp) to painful stimuli, due to diminished Cannot communicate discomfort except by moaning or communicate discomfort or need to be turned. Has no sensory deficit, which would limit
respond level of consciousness or sedation restlessness. OR ability to feel or voice pain or discomfort.
meaningfully to OR OR Has some sensory impairment, which limits ability to
pressure-related Limited ability to feel pain over most of Has sensory impairment, which limits the ability to feel feel pain or discomfort in 1 or 2 extremities.
discomfort. body surface. pain or discomfort over ½ of the body.
Moisture Constantly Moist Moist Occasionally Moist Rarely Moist
Degree to which Skin is kept moist almost constantly by Skin is often but not always moist. Linen must be Skin is occasionally moist, requiring an extra linen Skin is usually dry; linen requires changing only
skin is exposed to perspiration, urine, etc. Dampness is changed at least once a shift. change approximately once a day. at routine intervals.
moisture. detected every time patient is moved or
turned.
Activity Bedfast Chair fast Walks Occasionally Walks Frequently
Degree of Confined to bed. Ability to walk severely limited or nonexistent. Walks occasionally during day but for very short Walks outside the room at least twice a day and
physical activity. Cannot bear own weight and/or must be assisted into distances, with or without assistance. Spends majority inside the room at least once every 2 hours
chair or wheelchair. of each shift in bed or chair. during waking hours.
Mobility Completely Immobile Very Limited Slightly Limited No Limitations
Ability to change Does not make even slight changes in body Makes occasional slight changes in body or extremity Makes frequent though slight changes in body or Makes major and frequent changes in position
and control body or extremity position without assistance. position but unable to make frequent or significant extremity position independently. without assistance.
position. change independently.
Nutrition Very Poor Probably Inadequate Adequate Excellent
Usual food intake Never eats a complete meal. Rarely eats a complete meal. Eats over ½ of most meals. Eats most of every meal.
pattern. Rarely eats more than 1/3 of any food Generally eats only about 1/3 of any food offered. Eats a total of 4 servings of protein (meat and dairy Never refuses a meal.
offered. Protein intake includes only 3 servings of meat or dairy products) each day. Usually eats a total of 4 or more servings of
Eats 2 servings or less of protein (meat or products per day. Occasionally will refuse a meal, but will usually take a meat and dairy products. Occasionally eats
dairy products) per day. Occasionally will take a dietary supplement. supplement if ordered. between meals.
Take fluids poorly. OR OR Does not require supplementation.
Does not take a liquid dietary supplement. Receives less than optimum amount of liquid diet or Is on tube feeding or TPN regimen, which probably
OR tube feeding. meets most of nutritional needs.
Is NPO and/or maintained on clear liquids
or IV for more than 5 days.
Friction & Problem Potential Problem No apparent problem
Shear Requires moderate to maximum assistance Moves feebly or requires minimum assistance. Moves in bed and in chair independently and has
in moving. During a move, skin probably slides to some extent sufficient muscle strength to lift up completely during
Complete lifting without sliding against against sheets, chair, restraints or other devices. move.
sheets is impossible. Maintains relatively good position in chair or bed most Maintains good position in bed or chair at all times.
Frequently slides down in bed or chair, of the time but occasionally slides down.
requiring frequent repositioning with
maximum assistance.
Spasticity, contractions or agitation lead to
almost constant friction.

Source: Pressure Ulcers in Adults: Prediction and Prevention. Quick Reference Guide for Clinicians. AHCPR Publication No.92-0050. U.S. Department of Health and Human Services. May 1992.
12/8/2021
 Pressure Ulcer Intervention Guidelines Based on Braden Score
Braden Category Braden Score: 1 Braden Score: 2 Braden Score: 3 Braden Score: 4

Sensory Perception Completely limited Very limited Slightly limited No limitation

Skin assessment and inspection q shift. Surface: assess for specialty mattress or bed. Encourage patient to report pain over boney
Surface: assess for specialty mattress or bed. Use bed cradle under linen. prominences.
Use bed cradle under linen. No interventions required.
Use pillows between knees and boney prominences to
avoid direct contact.
Moisture Constantly Moist Moist Occasionally Moist Rarely Moist
Skin assessment and inspection q shift. Use moisture barrier ointments (Protective Use moisture barrier ointments (Protective barriers) Encourage patient to use lotion to prevent skin
Use moisture barrier ointments (Protective barriers) barriers) Moisturize dry unbroken skin. cracks.
Moisturize dry unbroken skin. Moisturize dry unbroken skin. Avoid hot water. Use mild soap and soft cloths. Encourage patient to report any moisture
Avoid hot water. Use mild soap and soft cloths. Avoid hot water. Use mild soap and soft Avoid use of diapers problem (such as under breasts.)
If diapers must be used, leave open as much as cloths. No interventions required.
possible. Avoid use of diapers
Apply condom catheter if appropriate.
Rectal tubes if appropriate
Activity Bed fast Chair fast Walks Occasionally Walks Frequently
*Use lifts and hover Skin assessment and inspection q shift. Provide trapeze. Provide structured mobility plan. Encourage ambulating outside the room at
mats with Position prone if appropriate Consider postural alignment, weight Consider physical therapy consult (done by MD.) least bid.
positioning. Position with pillows to elevate pressure points off of distribution, balance, stability, and pressure No interventions required.
the bed. relief when positioning individuals in chair or
wheelchair.
Provide appropriate seating surface.
Instruct patient to reposition q 15-30 minutes
when in chair.
Pad boney prominences with foam wedges,
rolled blankets or towels.
Consider physical therapy consult (done by
MD.)
Mobility Completely Immobile Very Limited Slightly Limited No Limitations
*Use lifts and hover Skin assessment and inspection q shift. Turn q 2 hours. Ensure patient turns q 2 hours. Encourage ambulating outside the room at
mats with Turn q 1-2 hours. Post turning schedule. least bid.
positioning. Post turning schedule. No interventions required.
Frequent small shifts of body weight.
Nutrition Very Poor Probably Inadequate Adequate Excellent
Skin assessment and inspection q shift. Nutrition Consult Nutrition Consult (if patient has a wound.) Nutrition Consult (if patient has a wound.)
Nutrition Consult Offer Nutrition Supplements Monitor nutritional intake Out of bed for all meals.
Offer Nutrition Supplements Monitor Nutritional Intake Offer Nutrition Supplements (if patient has a wound.) Provide food choices.
Monitor Nutritional Intake Small frequent meals Encourage family to bring favorite foods. Offer Nutrition Supplements (if patient has a
If NPO for > 24 hours, discuss plan with MD If NPO for > 24 hours, discuss plan with MD If NPO for > 24 hours, discuss plan with MD wound.)
If NPO for > 24 hours, discuss plan with MD
Friction & Shear Problem Potential Problem No apparent problem
*Use lifts and hover Skin assessment and inspection q shift. Keep bed linens clean, dry, and wrinkle-free. Keep bed linens clean, dry, and wrinkle-free.
mats with Minimum of 2 people + draw sheet to pull patient up Avoid massaging pressure points.
positioning. in bed. Apply transparent dressing or elbow/heel
Keep bed linens clean, dry, and wrinkle-free. protectors to intact skin over elbows and heels.
Apply transparent dressing or elbow/heel protectors
to intact skin over elbows and heels.
Elevate head of bed as little as possible and for as
little time as possible.

Source: Pressure Ulcers in Adults: Prediction and Prevention. Quick Reference Guide for Clinicians. AHCPR Publication No.92-0050. U.S. Department of Health and Human Services. May 1992.
12/8/2021