| 1 | 2 | 3 | 4 | |
| Sensory perceptions | Completely limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli due to diminished level of consciousness or sedation or limited ability to feel pain over most of the body. | Very limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness or has a sensory impairment which limits the ability to feel pain or discomfort over half of the body. | Slightly limited Responds to verbal commands but cannot always communicate discomfort or the need to be turned. or Has some sensory impairment which limits the ability to feel pain or discomfort in one or two extremities. | No impairment Responds to verbal commands. Has no sensory deficit which would limit the ability to feel or express pain or discomfort. |
| Moisture | Constantly moist Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time the patient is moved or turned. | Very moist Skin is often, but not always, moist. Linen must be changed at least once a shift. | Occasionally moist Skin is occasionally moist. Requires an extra linen change approximately once a day. | Rarely moist Skin is usually dry. Requires linen changes only at routine intervals. |
| Activity | Bedfast Confined to bed. | Chairfast Ability to walk is severely limited or nonexistent.Cannot bear own weight and/or must be assisted into chair or wheelchair. | Walks occasionally Walks occasionally during day, but for very short distances, with or without assistance.Spends majority of each shift in bed or chair | Walks frequently Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours. |
| Mobility | Completely immobile Does not make even slight changes in the body or extremity position without assistance. | Very limited Makes occasional light changes in body or extremity position but unable to make frequent or significant changes independently. | Slightly limited Makes frequent though slight changes in body or extremity position independently. | No limitation Makes major and frequent changes in position without assistance. |
| Nutrition | Very poor Never eats a complete meal. Rarely eats more than one-third of any food offered. Eats ≤2 servings of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement or is NPO and/or maintained on clear liquids. | Probably inadequate Rarely eats a complete meal and generally eats only about half of any food offered. Protein intake includes only three servings of meat or dairy products per day. Occasionally will take a dietary supplement or receives less than optimum amount of liquid diet or tube feeding. | Adequate Eats over half of most meals. Eats a total of four servings of protein (meat, dairy products per day). Occasionally will refuse a meal, but will usually take a supplement when offered or is on a tube feeding or total parenteral nutrition (TPN) regimen which probably meets most of the nutritional needs. | Excellent Eats most of every meal. Never refuses a meal. Usually eats ≥4 servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation. |
| Friction and shear | Problem Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair. Spasticity, contractures, or agitation leads to almost constant friction. | Potential problem Moves feebly or requires minimum assistance. During a move, the skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down | No apparent problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during the move. Maintains good position in bed or chair. | N/A |
Interpretation of Braden Scale
| Score | Interpretation |
| 19-23 | Not at risk. |
| 15-18 | Preventive interventions. |
| 13-14 | Moderate risk. |
| 10-12 | High risk. |
| 6-9 | Very high risk. |