Braden Score for Pressure Ulcers

Estimates a patient’s risk of developing pressure sores based on six clinically assessed risk factors.

Sensory perception*

No impairment: responds to verbal commands and can feel and communicate pain or discomfort+4

Slightly limited: responds to verbal commands but may not always communicate discomfort or need for repositioning+3

Very limited: responds mainly to painful stimuli or has sensory impairment affecting about half of the body+2

Completely limited: unresponsive to painful stimuli or unable to feel pain over most of the body+1

Moisture*

Rarely moist: skin is usually dry and linen changes are routine+4

Occasionally moist: requires approximately one additional linen change per day+3

Very moist: skin is frequently moist and linen requires changing at least once per shift+2

Constantly moist: skin is almost always moist from perspiration, urine, or similar sources+1

Activity*

Walks frequently: walks outside the room at least twice daily and inside regularly while awake+4

Walks occasionally: walks short distances but spends most of the shift in bed or a chair+3

Chairfast: walking is severely limited or absent and assistance is required for chair or wheelchair transfer+2

Bedfast: confined to bed+1

Mobility*

No limitation: makes major and frequent position changes without assistance+4

Slightly limited: makes frequent small position changes independently+3

Very limited: makes occasional small position changes but cannot reposition frequently or substantially without help+2

Completely immobile: cannot make even slight position changes without assistance+1

Nutrition*

Excellent: eats most meals, usually consumes at least 4 servings of protein daily, and does not require supplementation+4

Adequate: eats more than half of most meals and generally meets nutritional needs, including through tube feeding or TPN when applicable+3

Probably inadequate: rarely finishes meals, has limited protein intake, or receives less than optimal enteral nutrition+2

Very poor: eats very little, has poor fluid intake, or has been NPO/on clear liquids or IV fluids for more than 5 days+1

Friction and shear*

No apparent problem: moves independently and maintains good positioning without sliding+3

Potential problem: moves weakly or needs minimal assistance and may occasionally slide against surfaces+2

Problem: requires moderate to maximum assistance and frequently slides or experiences substantial friction+1