Raising the Braden Scale to lower pressure injuries

Why elevating the Braden Scale from routine task to top tool helps nurses better understand and prevent pressure injuries.

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You have a variety of tools for helping to prevent, assess and treat pressure injuries. The focus of this story: the Braden Scale for Predicting Pressure Sore Risk. Developed by Barbara Braden and Nancy Bergstrom in 1984,1 and now used in more than two dozen countries, the Braden Scale is an evidence-based tool that provides strong risk assessment value when used correctly. It’s a quantitative and universal standard that’s reproduceable, keeps staff accountable and helps improve patient care.

The Braden Scale helps you:

Identify patients at risk for pressure injuries.
Reduce the incidences of pressure injuries.
Determine the right care plan based on patients’ risk factors.
Decrease costs by preventing pressure injuries before they reach severe levels.

Despite these benefits, over the years, the power of the Braden Scale has waned. It’s typically seen as “a check box instead of a lesson,” says Katie James, BA, RN, CWCN, Medline Clinical Education Specialist. Bedside nurses are required to complete this formal assessment, but they might not be taking full advantage of it. “They kind of spit-shine it, and no one really goes into a deep dive,” James says. It might be time to get reacquainted with the Braden Scale and all it can do to help understand and prevent pressure injuries.

5 Ways to elevate the Braden Scale

  1. Use the subscales
    The Braden Scale can have a score from 6 to 23. The lower the score, the greater the risk for developing a pressure injury. But it’s important to remember that this score is the sum of six subscores from six subscales that measure sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Five of the subscales can have individual scores from 1 to 4; friction and shear is scored from 1 to 3. These subscores have their own stories to tell. “Any score of 1 in a subscore should signal the patient is at high risk for wounds. However, the forms used by most institutions I have seen do not include this information,” notes Dr. Ilene Warner-Maron, PhD, RN-BC, CWCN, CALA, NHA, FCPP, assistant professor at the Philadelphia College of Osteopathic Medicine and program director of the Nursing Home Administration Program at the University of Delaware. In fact, in 2012, Braden Scale developer Barbara Braden, Ph.D., RN, FAAN recommended that nurses use each subscore as “an initial appraisal of a patient’s specific problems and functional deficits.” 1 This valuable information can help nurses do the right thing.
  2. Allow for more clinical judgment
    Katie James notes, “The average patient today comes in with six comorbidities.” Some of these are not measured by the Braden Scale and therefore not always factored into the risk assessment for pressure injuries. This is where good nursing judgment is key. “Staff overestimate the Braden Scale score,” Dr. Warner-Maron says. “As a consequence, there is a missed opportunity to put into place reasonable interventions to reduce the development of pressure injuries.” For example, the presence of an existing pressure injury or history of past pressure injuries are relevant in determining a patient’s risk for future wounds, as are factors such as advanced age, low diastolic blood pressure, increased body temperature, low protein intake, recent weight loss, and use of chemotherapy or steroids.2 But the Braden Scale doesn’t account for any of those conditions. The takeaway: it’s important for administrators to understand the inherent issues involved in risk assessments and to expect that nurses will use their nursing judgment.
  3. Create shortcuts
    While the Braden Scale contains pertinent information, Katie James notes that time-starved nurses could benefit from a condensed version. Short phrases for each category and associated score could help nurses memorize the basics. Something like “Bedfast, can’t turn” would be a 1. Or, James suggests a Braden Scale smart phone app suitable for use by bedside nurses.
  4. Educate staff
    Staff education is key to helping care for patients and reduce the number of pressure injuries. In fact, Dr. Warner-Maron has reviewed many malpractice cases from hospitals, nursing homes and home health care, and 50 percent of them have dealt with pressure injuries. She stresses, “It is vital that nurses have the education and support they need to complete the Braden Scale correctly.” However, in many cases frontline nurses haven’t been taught the Braden Scale in nursing school, according to Kara S. Couch, MS, CRNP, CWCN-AP, George Washington University. To help with this, Warner-Maron suggests running through patient scenarios with nurses using the Braden Scale. James suggests lunch-and-learn type education to help fit Braden Scale education into busy nurse schedules. Better education isn’t always easy, but it’s worth the time.
  5. Customize protocols
    Determining a Braden Scale score and factoring in nursing judgment is just the beginning. Using those numbers to prevent pressure injuries is the most important step. You can save time by creating standard prevention protocols based on Braden total scores and each subscore. Because your health care facility is unique in terms of staffing, wound care specialists and products used, it helps to work with leadership and a trusted supply vendor who understands the complexities of wound assessment to develop specific protocols that fit your facility.

Make the most of the Braden Scale

The Braden Scale is a staple of wound assessment; knowing how to make the most of it can help frontline nurses make the right decisions on preventing and treating pressure injuries. For more best practices, tools and education surrounding wound care, visit Medline University.

Note: To utilize the Braden Scale in your health care facility, visit and complete the Permission Request form.