Factors that place a patient at risk for developing a pressure injury:

 decreased sensory perception

 increased moisture
 decreased activity
 impaired mobility
 inadequate nutrition

What is a Braden Scale?

 The Braden Scale is a standardized, evidence-based assessment tool commonly used in health
care to assess and document a patient’s risk for developing pressure injuries.
 Risk factors are rated on a scale from 1 to 4, with 1 being “completely limited” and 4 being “no
impairment.” The scores from the six categories are added, and the total score indicates a
patient’s risk for developing a pressure injury based on these ranges:
Mild risk: 15-18
Moderate risk: 13-14
High risk: 10-12
Severe risk: less than 9
The lower the score, the higher the risk of developing a pressure injury. Additionally, customized nursing
interventions are implemented based on the rating in each category. The higher the score, the more
aggressive actions are taken to prevent or heal a pressure injury. Descriptions of the ratings from 1-4 for
each risk factor, along with targeted interventions for each rating, are further described in the following
subsections.

Sensory perception
The sensory perception risk factor is defined as the ability to respond meaningfully to pressure-related
discomfort. If a patient is unable to feel pressure-related discomfort and respond to it appropriately by
moving or reporting pain, they are at high risk of developing a pressure injury. This risk category
describes two different issues that affect sensory perception. The first description refers to the patient’s
level of consciousness, and the second description refers to the patient’s ability to feel cutaneous
sensation.

Rating Description
4–No Impairment: Responds to verbal commands. Has no sensory deficit that would limit ability to feel
or voice pain or discomfort.
Interventions: Encourage the patient to report pain over bony prominences. Check heels daily.

Moisture
The moisture risk factor is defined as the degree to which skin is exposed to moisture. Prolonged
exposure to moisture increases the probability of skin breakdown. Moisture can come from several
sources, such as perspiration, urine incontinence, stool incontinence, or wound drainage. Frequent
surveillance, removal of wet or soiled linens, and use of protective skin barriers greatly reduce this risk
factor.

Activity
The activity risk factor is defined as the degree of physical activity. For example, walking or moving from
a bed to a chair reduces a patient’s risk of developing a pressure injury by redistributing pressure points
and increasing blood and oxygen flow to areas at risk.
Level of activity is defined by how frequently the patient is able to get out of bed, move into a chair, or
ambulate with or without help.

Mobility
The mobility risk factor is defined as the patient’s ability to change or control their body position. For
example, healthy people frequently change body position by rolling over in bed, shifting weight in a
chair after sitting too long, or by moving their extremities. However, tissue damage will occur if a patient
is unable to reposition on their own power unless caregivers frequently change their position.

Nutrition
Adequate nutrition and fluid intake are vital for maintaining healthy skin. Protein intake, in particular, is
very important for healthy skin and wound healing. The nutrition risk factor is defined by two categories
of descriptions. The first category measures the amount and type of oral intake. The second category is
used for patients receiving tube feeding, total parenteral nutrition (TPN), or are prescribed clear liquid
diets or nothing by mouth (NPO).

Friction/Shear
Friction and shear are significant risk factors for producing pressure injuries. This category only has three
ratings, unlike the other categories that have four ratings, and is rated by whether the patient has a
problem, potential problem, or no apparent problem in this area. See Table 10.5f for interventions for
each level of risk.
Figure 1. Braden Scale Assessment