Braden scale for pressure injury risk
Pressure injury risk in hospitalized and long-term care patients.
Inputs
CompleteSensory perception
Moisture
Activity
Mobility
Nutrition
Friction and shear
Worked calculation
Your values are highlighted.
- Points
Sensory perception +4, Moisture +4, Activity +4, Mobility +4, Nutrition +4, Friction and shear +3= 23
When to use
- On admission and at regular intervals.
Pearls and pitfalls
- Lower is worse: 18 or below indicates risk in most settings.
Why use
The standard nursing risk tool.
| Criterion | Points |
|---|---|
| Sensory perception: Completely limited | +1 |
| Very limited | +2 |
| Slightly limited | +3 |
| No impairment | +4 |
| Moisture: Constantly moist | +1 |
| Very moist | +2 |
| Occasionally moist | +3 |
| Rarely moist | +4 |
| Activity: Bedfast | +1 |
| Chairfast | +2 |
| Walks occasionally | +3 |
| Walks frequently | +4 |
| Mobility: Completely immobile | +1 |
| Very limited | +2 |
| Slightly limited | +3 |
| No limitation | +4 |
| Nutrition: Very poor | +1 |
| Probably inadequate | +2 |
| Adequate | +3 |
| Excellent | +4 |
| Friction and shear: Problem | +1 |
| Potential problem | +2 |
| No apparent problem | +3 |