BRADEN SCALE – For Predicting Pressure Sore Risk

SEVERE RISK: Total score 9 HIGH RISK: Total score 10-12 DATE OF
MODERATE RISK: Total score 13-14 MILD RISK: Total score 15-18 ASSESS 

RISK FACTOR SCORE/DESCRIPTION 1 2 3 4

SENSORY 1. COMPLETELY 2. VERY LIMITED – 3. SLIGHTLY 4. NO

PERCEPTION LIMITED – Responds only to LIMITED – Responds IMPAIRMENT –
Ability to Unresponsive (does painful stimuli. to verbal Responds to verbal
respond not moan, flinch, or Cannot commands but commands. Has no
meaningfully grasp) to painful communicate cannot always sensory deficit which
to stimuli, due to discomfort except by communicate would limit ability to
pressure- diminished level of moaning or discomfort or need to feel or voice pain or
related consciousness or restlessness, be turned, discomfort.
discomfort sedation, OR OR
OR has a sensory has some sensory
limited ability to feel impairment which impairment which
pain over most of limits the ability to limits ability to feel
body feel pain or discomfort pain or
surface. over ½ of body. discomfort in 1 or 2
extremities.

MOISTURE 1. CONSTANTLY 2. OFTEN MOIST – 3. OCCASIONALLY 4. RARELY MOIST –

Degree to which MOIST– Skin is kept Skin is often but not MOIST – Skin is Skin is usually dry;
skin is exposed always moist. Linen linen only requires
moist almost occasionally moist,
to moisture constantly by must be changing at
changed at least requiring an extra
perspiration, urine, linen change routine intervals.
etc. Dampness is once a shift.
approximately once
detected every time a day.
patient is
moved or turned.

ACTIVITY 1. BEDFAST – 2. CHAIRFAST – 3. WALKS 4. WALKS

Degree of Confined to bed. Ability to walk OCCASIONALLY – FREQUENTLY–
physical severely limited or Walks occasionally Walks outside the
activity nonexistent. Cannot during day, but for room at least twice a
bear own weight very short day and inside room
and/or must be distances, with or at least once every 2
assisted into without assistance. hours during waking
chair or wheelchair. Spends hours.
majority of each
shift in bed or chair.

MOBILITY 1. COMPLETELY 2. VERY LIMITED – 3. SLIGHTLY 4. NO

Ability to IMMOBILE – Does Makes occasional LIMITED – Makes LIMITATIONS –
change and not make even slight slight changes in frequent though Makes major and
control body changes in body or body or slight changes in body frequent changes in
position extremity extremity position or extremity position position without
position without but unable to make independently. assistance.
assistance. frequent or
significant changes
independently.

NUTRITION 1. VERY POOR – 2. PROBABLY 3. ADEQUATE – 4. EXCELLENT – Eats

Usual food Never eats a complete INADEQUATE – Eats over half of most of every meal.
intake pattern meal. Rarely eats Rarely eats a most meals. Eats a Never refuses a meal.
more than 1/3 of any complete meal and total of 4 servings of
Usually eats a total of
1
NPO: food offered. Eats 2 generally eats only protein (meat, dairy
4 or more servings of
Nothing by servings or less of about ½ of any food products) each day.
meat and dairy
mouth. protein (meat or offered. Protein intake Occasionally refuses a products.
2
IV: dairy products) per includes only 3 meal, but will usually
Intravenously. day. Takes fluids take a supplement if Occasionally eats
servings of meat or between meals. Does
3
TPN: Total poorly. Does not dairy products per day. offered, OR
take a liquid dietary is on a tube feeding not require
parenteral Occasionally will take a supplementation.
nutrition. supplement, dietary supplement or TPN3regimen,
OR OR which
is NPO1and/or probably meets
receives less than most of nutritional
maintained on clear optimum amount of needs.
liquids or IV2for liquid diet or tube
more than 5 days. feeding.

FRICTION 1. PROBLEM- 2. POTENTIAL 3. NO APPARENT

 AND SHEAR Requires moderate PROBLEM– Moves PROBLEM –
to maximum feebly or requires Moves in bed and
assistance in moving. in chair
Complete lifting minimum assistance.
independently and has
without sliding During a move, skin sufficient muscle
against sheets is probably slides to strength to lift up
impossible. some extent against completely
Frequently slides sheets, chair, during move.
down in bed or restraints, or other Maintains good
chair, requiring devices. Maintains position in bed or
frequent relatively good chair at all times.
repositioning with position in chair or
maximum assistance. bed most of the time
Spasticity, but occasionally
contractures, or slides down.
agitation leads to
almost constant friction.

TOTAL Total score of 12 or less represents HIGH RISK

SCORE
ASSESS DATE EVALUATOR SIGNATURE/TITLE ASSESS. DATE EVALUATOR SIGNATURE/TITLE

1 // 3 //

2 // 4 //

Attending Physician Record No.

NAME-Last First Middle Room/Bed

Form 3166P BRIGGS, Des Moines, IA 50306 (800) 247-2343 Copyright, 1988. Reprinted with permission. Permission www.bradenscale.com
www.BriggsCorp.com R304 PRINTED IN U.S.A should be sought to use this tool at
Source: Barbara Braden and Nancy Bergstrom. BRADEN SCALE

Use the form only for the approved purpose. Any use of the form in publications (other than internal policy manuals and training material) or for profit-making ventures requires additional permission and/or negotiation.