1. Braden Scale Sensory Subsection
For subsection scores 1 or 2 always apply the high risk interventions!
Sensory 4
No Impairment 3
Slightly Limited 2
Very Limited 1
Completely Limited
Assess Patients Ability To Respond Meaningfully To Pressure Related Discomfort!
Responds to verbal command
No sensory deficit which would limit ability to feel of voice pain or discomfort
Responds to verbal commands
Cannot always communicate discomfort or need to be turned
Sensory impairment that limits ability to feel pain in 1 or 2 extremities
Responds only to painful stimuli
Ability to communicate discomfort limited to moaning and/or restlessness
Sensory impairment that limits ability to feel pain over ½ of body
Unresponsive to painful stimuli due to diminished consciousness or sedation
Does not moan, flinch or grasp
Limited ability to feel pain over most of body surface
High Risk Interventions
High Risk Low Risk
Ensure heels are off of bed surfaces
Ensure patient is not lying on objects and/or lines, tubes, and drains
Turn every 2 hours with 30 degree tilt
Select and apply appropriate surfaces
Apply bordered foam to the appropriate risk areas

2. Braden Scale Moisture Subsection
For subsection scores 1 or 2 always apply the high risk interventions!
Moisture 4
EXCELLENT 3
ADEQUATE 2
PROBABLY INADEQUATE 1
VERY POOR
Identify Moisture Risk And Keep The Patient Clean And Dry!
Rarely Moist
Skin is usually dry
Occasionally Moist
Occasional perspiration, drainage, and/or incontinence
Requires one linen change per day
Often Moist
Frequent perspiration, drainage, and/or incontinence
Requires one linen change per shift
Constantly Moist
Constant perspiration, drainage, and/or incontinence.
Requires two or more linen changes per shift
Requires change at routine intervals
High Risk Low Risk
High Risk Interventions
Apply skin protectant barriers
Offer toileting assistance every 2 hours
Consider low air loss surface
Consider incontinence management devices as appropriate
Only use briefs while ambulating

3. Braden Scale Activity Subsection4
WALKS FREQUENLY 3
WALKS OCCASIONALLY 2
CHAIRFAST 1
BEDBOUND
For subsection scores 1 or 2 always apply the high risk interventions!
Identify The Patients Degree Of Physical Activity!
Walks frequently in the room
Walks outside of the room at least twice a day
Walks occasionally in room
Walks occasionally in very short distances
Ability to walk severely limited or nonexistent
Cannot bear own weight and/or must be assisted into chair or wheelchair
Minimum x 1 assist for all out of bed activities
Confined to bed
High Risk Low Risk
High Risk Interventions
Identify the patient’s activity level, level of assistance and appropriate DME
If chairfast or bedbound apply pressure relief surfaces to alleviate pressure
Turn every 2 hours with 30 degree tilt

4. Braden Scale Mobility Subsection
For subsection scores 1 or 2 always apply the high risk interventions!
Mobility 4
NO LIMITATION 3
SLIGHTLY LIMITED 2
VERY LIMITED 1
COMPLETELY IMMOBILE
Identify The Patients Ability To Change And Control Body Positions!
Makes major and frequent changes in position
Does not need assistance to change position in bed or while in chair
Makes frequent though slight changes in position
Minimal or no assistance needed with positioning
Makes occasional or slight body and/or extremity position
Needs assistance with repositioning minimum x1 assist
Does not make even slight changes in body or extremity position
Total care- minimum x2 assist
High Risk Interventions
High Risk Low Risk
Assist to chair position for all meals; at least twice daily
Apply appropriate pressure relief surfaces
Turn every 2 hours with 30 degree tilt
Do not use donuts or rings
Shift weight every 15 minutes while up in chair

5. Braden Scale Nutrition Subsection
For subsection scores 1 or 2 always apply the high risk interventions!
Nutrition 4
EXCELLENT 3
ADEQUATE 2
PROBABLY INADEQUATE 1
VERY POOR
Identify The Patients Usual Food Intake Pattern!
Eats most of all meals & never refuses food
Does not require or need supplements
Eats over half of most meals
May refuse a meal but will take a supplement
On Tube Feeding or TPN
Generally eats ½ of food offered
Occasionally may take a supplement
Receives less than desired goal for tube feeding
Rarely eats at least ½ of food offered
Does not take supplements
TPN, clear liquids or NPO for greater than 5 days
High Risk Interventions
High Risk Low Risk
Assess nutritional intake each shift
Obtain dietary consult order
Offer fluids with each encounter
Promote dietary supplements
Monitor weight weekly, as ordered or per unit standard of care

6. Braden Scale Friction & Shear Subsection
For subsection scores 1 or 2 always apply the high risk interventions!
Friction/Shear 3
NO APPARENT PROBLEM 2
POTENTIAL PROBLEM 1
PROBLEM
Identify The Patients Level Of Friction And Shear!
Mobility independent with good strength and positioning
Does not require assistance with positioning
Requires some (25%) help, moves feebly
While moving, skin slides on sheets, chairs, etc.
Occasionally slides in bed or chair
Requires a lot of help (50–75%)
Frequently slides in chair, frequently requires assist to reposition
Spasticity, contractures, agitation present
High Risk Interventions
High Risk Low Risk
Utilize positioning and offloading regularly
Use appropriate surfaces to reduce and relieve pressure
Apply barriers and dressings to reduce shear and friction
Consider PT consult to promote mobility