Braden scale score and pressure injury risk

The Braden Scale is the standard tool for judging a client's risk of developing a pressure injury. On the NCLEX-RN, it is a place where you add up a score and then act on it. The arithmetic is easy. What the exam checks is whether you remember which direction the score runs, what the bands are and what the nurse does with the number. The Braden scale calculator will total the six subscales for you while you practice.

This is a study aid, not clinical guidance. Your nursing program, facility policy and state board decide how risk is assessed and managed in practice. The official Braden form is copyrighted, so this post describes what each subscale looks at in plain words and does not reproduce the form's wording.

What a pressure injury is

A pressure injury is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical device. It comes from intense or prolonged pressure combined with shear. It can be intact skin or an open ulcer. External pressure above arterial capillary pressure, about 32 mm Hg, stops blood flow, and that causes ischemia and necrosis.

A bedridden client can begin to develop a pressure injury within a few hours, so prevention starts at the beginning of the stay, not after the skin breaks down. Hospital-acquired or worsening pressure injuries are preventable and reportable events.

The six subscales

The Braden Scale has six subscales. Each one looks at a different reason the skin might be exposed to damage:

1. Sensory perception. Can the client feel pressure and discomfort and tell you or move in response?
2. Moisture. How often is the skin wet from sweat, urine, stool or drainage?
3. Activity. How much does the client walk or get out of bed?
4. Mobility. Can the client change and control body position without help?
5. Nutrition. What is the client's usual eating pattern?
6. Friction and shear. Does the skin slide or drag against surfaces when the client is moved or slides down in bed?

Each subscale gets its own score, and the six scores are added to give the total.

Reading the total

The total runs from 6 to 23. The lower the score, the higher the risk. That is the single most tested fact about the scale, and it is the opposite of what many people expect, because on other scales a bigger number means a sicker client.

The risk bands used in the course are:

Another textbook calls a total of 12 or less "high risk," which agrees with the table, since 10 to 12 is high and 9 or less is severe. Bands can be worded differently by different programs and facilities, so learn the version your course uses and expect the exam to give you the numbers it needs. A quick way to keep the direction straight: low score, high risk.

When it is done

Braden is typically completed on admission and repeated per policy, for example every shift, and again when the client's condition changes. A skin assessment is done with each repositioning.

Document the skin condition on admission. That record is what keeps an existing pressure injury from being recorded as hospital-acquired.

A worked example

A client is admitted after a stroke. The nurse scores the six subscales:

The total is 3 + 2 + 2 + 2 + 2 + 1 = 12. That is in the 10 to 12 band, which is high risk. You can enter the same numbers in the calculator to check the sum.

What follows from the number is the part the exam cares about. The score is used to trigger interventions, not just to record a number. For this client the nurse would move to off-loading pressure, choose a suitable support surface, keep the skin clean and dry, and plan repositioning. A pillow between the knees in side-lying position prevents pressure injury, and a bedridden client needs pressure, friction and shear minimized from the start. Your program or facility policy decides the exact schedule and equipment.

Exam traps

• Direction of the score. Lower is worse. A client who goes from 16 to 11 has become higher risk.
• Score versus stage. Braden predicts risk before injury. Staging describes an injury that already exists, and only pressure injuries are staged.
• Not every wound is a pressure injury. Moisture-associated skin damage, incontinence-associated dermatitis and skin tears are not staged as pressure injuries.
• A new nonblanchable red area over a bony prominence is a stage 1 pressure injury. The priority is to off-load it right away and step up prevention, not wait for the skin to open.
• Purple, maroon or deep red skin that does not blanch points to deep tissue injury, not stage 1. Document, off-load and report.

Where it sits in the course and the exam

Skin integrity and pressure injuries are in the mobility, skin and elimination unit of the free NCLEX-RN course, and risk tools like Braden also appear in the assessment unit. What's in the free NCLEX-RN deck maps both. The content belongs to Basic Care and Comfort, which the test plan weights at 6 to 12 percent, and the way categories are weighted is explained in the client needs categories. Questions about who does the skin assessment or turns the client often turn into delegation items, so NCLEX priority and delegation questions is a useful companion.

How to study it

The scale is small and exact, so it suits retrieval practice:

• Write the six subscales from memory, then check.
• Make a card for the direction of the score and one for each band cutoff.
• Total two or three example clients by hand before you use a calculator. The testing effect explains why that works better than rereading, and how to memorize a list, a table or a formula sheet covers the table method.

If you also study for the NREMT, skin assessment shows up there as well. The rule of nines for burns post and the rule of nines calculator cover burn estimates, and EMT patient assessment, step by step shows how assessment order is tested. For the full plan around the course, read how to study for the NCLEX-RN.