Braden Risk Assessment Scale NOTE: Bed and chairbound individuals or those with impaired ability to reposition should be assessed upon admission for their risk of 

developing pressure ulcers. Patients with established pressure ulcers should be reassessed periodically.

Patient Name: ________________________________________________ Room Number: ______ Date: _____________

SensoryPerception

Ability to respondmeaningfully to pressure-related discomfort

Moisture

Degree to which skinis exposed to moisture

Activity

Degree of physical activity

Mobility

Ability to change andcontrol body position

Nutrition

Usual food intake pattern

Frictionand Shear

1. Completely Limited

Unresponsive (does notmoan, flinch or grasp)to painful stimuli, dueto diminished level of consciousness or sedation.OR limited ability to feelpain over most ofbody surface.

1. Constantly Moist

Skin is kept moist almostconstantly by perspiration,urine, etc. Dampness isdetected every time patientis moved or turned.

1. Bedfast

Confined to bed.

1. Completely Immobile

Does not make evenslight changes in bodyor extremity positionwithout assistance.

1. Very Poor

Never eats a complete meal.Rarely eats more than 1/3of any food offered. Eats 2servings or less of protein(meat or dairy products)per day. Takes fluids poorly.Does not take a liquiddietary supplement. OR isNPO and/or maintained onclear liquids or I.V.’s formore than 5 days.

1. Problem

Requires moderate tomaximum assistance inmoving. Complete liftingwithout sliding againstsheets is impossible.Frequently slides down inbed or chair, requiringfrequent repositioningwith maximum assistance.Spasticity, contractures oragitation lead to almostconstant friction.

2. Very Limited

Responds only topainful stimuli. Cannotcommunicate discomfortexcept by moaning orrestlessness. OR has asensory impairment whichlimits the ability to feel painor discomfort over 1/2of body.

2. Very Moist

Skin is often, but notalways, moist. Linen mustbe changed at least oncea shift.

2. Chairfast

Ability to walk severelylimited or non-existent.Cannot bear own weightand/or must be assisted intochair or wheelchair.

2. Very Limited

Makes occasionalslight changes in bodyor extremity positionbut unable to makefrequent or significantchanges independently.

2. Probably Inadequate

Rarely eats a completemeal and generally eatsonly about 1/2 of any foodoffered. Protein intakeincludes only 3 servings of meat or dairy products perday. Occasionally will takea dietary supplement. ORreceives less than optimumamount of liquid diet ortube feeding.

2. Potential Problem

Moves feebly or requiresminimum assistance.During a move, skinprobably slides to someextent against sheets, chairrestraints, or other devices.Maintains relatively goodposition in chair or bedmost of the time, butoccasionally slides down.

3. Slightly Limited

Responds to verbalcommands, but cannotalways communicatediscomfort or need tobe turned. OR has somesensory impairmentwhich limits ability tofeel pain or discomfortin 1 or 2 extremities.

3. Occasionally Moist

Skin is occasionally moist,requiring an extra linenchange approximatelyonce a day.

3. Walks Occasionally

Walks occasionally duringday, but for very shortdistances, with or withoutassistance. Spends majorityof each shift in bed or chair.

3. Slightly Limited

Makes frequentthough slight changesin body or extremityposition independently.

3. Adequate

Eats over half of mostmeals. Eats a total of4 servings of protein (meat,dairy products) each day.Occasionally will refuse ameal, but will usually takea supplement if offered.OR is on a tube feedingor TPN regimen whichprobably meets most of nutritional needs.

3. No Apparent Problem

Moves in bed and in chairindependently and hassufficient muscle strengthto lift up completely duringmove. Maintains goodposition in bed or chairat all times.

4. No Impairment

Responds to verbalcommands. Has no sensorydeficit which would limitability to feel or voicepain or discomfort.

4. Rarely Moist

Skin is usually dry. Linenonly requires changing atroutine intervals.

4. Walks Frequently

Walks outside the room atleast twice a day and insideroom at least once every 2hours during waking hours.

4. No Limitations

Makes major and frequentchanges in positionwithout assistance.

4. Excellent

Eats most of every meal.Never refuses a meal.Usually eats a total of 4 ormore servings of meat anddairy products. Occasionallyeats between meals. Doesnot require supplementation.

 NOTE: Patients with a total score of 16 or less are considered to be at risk of developing pressure ulcers.

(15 or 16 = low risk; 13 or 14 = moderate risk; 12 or less = high risk)© Copyright Barbara Braden and Nancy Bergstrom, 1988

Total Score:

Indicate Appropriate Numbers Below