By Miranda, Nursing Student (BSN candidate)

This guide is currently pending review by a licensed clinical nurse.

Last updated: April 11, 2026

Braden Scale Scoring and Wound Documentation for Nurses

Braden Scale scoring looks simple on paper - 6 subscales, add them up, get a risk level. Then you try to score your first patient and realize the subscales are harder than they look. Is this patient "occasionally moist" or "very moist"? "Walks occasionally" or "chairfast"? I was stuck on my first three Bradens during my rotation. Here's the framework that finally let me score them in under 90 seconds once I'd done a few.

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Why This Matters

Regulatory bodies: Centers for Medicare & Medicaid Services (CMS), The Joint Commission, National Pressure Injury Advisory Panel (NPIAP)

Hospital-acquired pressure injuries (HAPIs) represent a CMS non-reimbursable event; a single Stage 3 or 4 HAPI can cost a hospital $20,000-$50,000 in non-reimbursed care. The Braden Scale serves as the most widely used pressure injury risk assessment tool in the US, and almost every hospital requires it upon admission. Braden scoring involves more than just paperwork; the score directly triggers intervention bundles such as turn schedules, specialty mattresses, and nutrition consults. Documenting pressure injury risk poses a litigation risk; missing or inadequate Braden documentation frequently appears in HAPI lawsuits.
  1. The Braden Scale for Predicting Pressure Sore Risk — Bergstrom N, Braden BJ et al. Nurs Res. 1987;36(4):205-210 (1987)
  2. Pressure Injury Prevention Clinical Practice Guideline — National Pressure Injury Advisory Panel (NPIAP) (2019)
  3. Increased bacterial burden and infection: NERDS and STONEES — Sibbald RG, Woo K, Ayello EA. Adv Skin Wound Care. 2006;19(8):447-461 (2006)
  4. Hospital-Acquired Conditions (HACs) - Pressure Ulcer Quality Measures — Centers for Medicare & Medicaid Services (2024)
  5. Preventing Pressure Ulcers in Hospitals: A Toolkit — Agency for Healthcare Research and Quality (AHRQ)

What the Braden Scale Measures

The Braden Scale is a 6-subscale tool that predicts pressure injury risk, with total scores ranging from 6 (highest risk) to 23 (lowest risk). It was developed by Barbara Braden and Nancy Bergstrom and published in 1987. It's currently the most widely used pressure injury risk assessment in US hospitals. The six subscales - sensory perception, moisture, activity, mobility, nutrition, and friction/shear - each measure a different dimension of pressure injury risk. The Braden is typically scored on admission and reassessed each shift for at-risk patients. It's standard across adult inpatient settings; pediatric and neonatal patients use different scales (Braden Q for pediatrics). One important note: the Braden Scale predicts risk - it doesn't diagnose a pressure injury. A patient can have a perfect Braden score and still develop a wound from a specific incident.

How to score each subscale

Each subscale features 3 or 4 descriptive levels. Use the standardized descriptors rather than your interpretation of what "moderate" means.

Sensory perception (1-4)

1 = Completely limited - unresponsive to painful stimuli OR limited ability to feel pain over most of body. 2 = Very limited - responds only to painful stimuli OR has sensory impairment over half of body. 3 = Slightly limited - responds to verbal commands but cannot always communicate discomfort OR has sensory impairment in 1-2 extremities. 4 = No impairment - responds to verbal commands, has no sensory deficit that limits ability to feel or voice pain.

Moisture (1-4)

1 = Constantly moist - skin is kept moist almost constantly by perspiration, urine, or other fluids; dampness detected every time patient is moved or turned. 2 = Very moist - skin is often but not always moist; linen must be changed at least once per shift. 3 = Occasionally moist - skin is occasionally moist, requiring an extra linen change approximately once per day. 4 = Rarely moist - skin is usually dry; linen only requires changing at routine intervals. The distinction between "very" and "occasionally" often confuses students - think in terms of linen changes per shift.

Activity (1-4)

1 = Bedfast - confined to bed. 2 = Chairfast - ability to walk severely limited or nonexistent; cannot bear own weight and must be assisted into chair or wheelchair. 3 = Walks occasionally - walks occasionally during day but for very short distances, with or without assistance; spends majority of each shift in bed or chair. 4 = Walks frequently - walks outside the room at least twice a day AND inside the room at least once every 2 hours during waking hours.

Mobility (1-4)

1 = Completely immobile - does not make even slight changes in body or extremity position without assistance. 2 = Very limited - makes occasional slight changes in body or extremity position but is unable to make frequent or significant changes independently. 3 = Slightly limited - makes frequent though slight changes in body or extremity position independently. 4 = No limitations - makes major and frequent changes in position without assistance. Activity and Mobility are separate subscales - a patient can be chairfast (Activity 2) but able to shift their weight frequently in the chair (Mobility 3).

Nutrition (1-4)

1 = Very poor - never eats a complete meal; rarely eats more than 1/3 of any food offered; takes fluids poorly; is NPO or on clear liquids or IV for more than 5 days. 2 = Probably inadequate - rarely eats a complete meal; generally eats only about 1/2 of food offered; receives less than optimum amount of liquid diet or tube feeding. 3 = Adequate - eats over half of most meals; occasionally refuses a meal but usually takes a supplement when offered OR is on tube feeding or TPN that probably meets most nutritional needs. 4 = Excellent - eats most of every meal; never refuses a meal; usually eats 4+ servings of protein; occasionally eats between meals.

Friction and shear (1-3)

Note: this subscale only has 3 levels, not 4 - the maximum score is 3. 1 = Problem - requires moderate to maximum assistance in moving; complete lifting without sliding against sheets is impossible; frequently slides down in bed or chair. 2 = Potential problem - moves feebly or requires minimum assistance; skin probably slides to some extent during a move against sheets, chair, or other devices. 3 = No apparent problem - moves in bed and chair independently and has sufficient muscle strength to lift up completely during a move.

Braden Risk Interpretation and Intervention Thresholds

The total Braden score indicates a risk level, which triggers a specific intervention bundle. Severe risk (≤9) requires Q1-2h repositioning, a specialty bed or surface, heel protection, a nutrition consult, a wound care consult, and daily skin assessments. High risk (10-12) necessitates Q2h repositioning, a pressure-redistributing surface, heel protection, a nutrition consult, and daily skin assessments. Moderate risk (13-14) involves Q2h repositioning, a pressure-redistributing surface, heel protection, and monitoring skin integrity. Mild risk (15-18) calls for Q4h repositioning, a pressure-redistributing surface, and monitoring skin integrity. Not at risk (≥19) requires standard prevention, which includes repositioning based on comfort and routine skin monitoring. Your unit may have different thresholds or intervention bundles; always follow your unit's protocol rather than a generic one from the internet. The thresholds above reflect common institutional practices and AHRQ toolkit recommendations.

Wound Documentation - The 6 Components

A complete wound assessment has 6 components. Document each one every time you assess the wound.

Wound Type and Stage

First, identify the wound type, as it determines the staging system and treatment approach. Common types include pressure injury, surgical wound, traumatic wound, arterial ulcer, venous ulcer, diabetic ulcer, burn, skin tear, and moisture-associated skin damage. For pressure injuries, use the NPIAP staging system: Stage 1 (intact skin with non-blanchable erythema), Stage 2 (partial-thickness loss with exposed dermis), Stage 3 (full-thickness skin loss), Stage 4 (full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone), Unstageable (full-thickness loss obscured by slough or eschar), and Deep Tissue Pressure Injury (persistent non-blanchable deep red, maroon, or purple discoloration).

Wound Measurements

Measure length × width × depth in centimeters. Length runs head to foot, while width runs side to side. Always maintain the same anatomical orientation to ensure measurements are trendable. For undermining, document clock positions and depth, such as "undermining 0.5 cm from 9 o'clock to 3 o'clock." For tunneling, document clock position and depth, for example, "tunneling at 12 o'clock, 1.2 cm deep." Measure at the same positions each time. Inconsistent measurement techniques hinder tracking whether the wound is improving or deteriorating.

Wound Bed Composition

Document the percentages of tissue types visible in the wound bed: granulation tissue (red - healthy, healing), slough (yellow - dead tissue, needs debridement), eschar (black - dead tissue, needs debridement), and any exposed structures (white/fibrinous tissue, bone, tendon). The percentages must total 100%. For example, state: "wound bed 60% red granulation, 30% yellow slough, 10% black eschar." Tracking wound bed composition over time indicates whether the wound is progressing toward healing or stalling.

Wound Edges

Document edge characteristics: attached (favorable - edges are migrating toward the wound center), rolled/epibole (unfavorable - edges have rolled under, suggesting stalled healing), advancing (favorable - new epithelial tissue migrating inward), or fibrotic (unfavorable - scarred edges that resist closure). Rolled edges serve as a clinical red flag that may require intervention.

Exudate

Document four characteristics: amount (none, scant, small, moderate, large), color (serous/clear, serosanguineous/pink, sanguineous/red, purulent/green or yellow), consistency (thin, thick, viscous), and odor (none, faint, moderate, strong - note whether odor persists after wound cleaning). Changes in exudate characteristics, especially increased amount, purulent color, or new odor, indicate early signs of infection.

Periwound Skin

Document the condition of the skin surrounding the wound: intact, macerated (white and softened from excess moisture), excoriated (abraded or eroded), indurated (firm or hard), or erythematous (red). Also document edema on a scale from 0 (none) to 4+ (severe). The periwound condition indicates whether your moisture management and dressing choice are appropriate.

NERDS and STONEES - Infection Identification

Sibbald et al.'s NERDS and STONEES criteria help distinguish superficial from deep wound infection. NERDS identifies superficial infection (3 of 5 criteria positive): Non-healing wound, Exudate increasing, Red friable granulation, Debris in the wound, Smell. STONEES identifies deep or surrounding infection (3 of 7 criteria positive): Size increasing, Temperature increased, Os (probes to bone), New satellite areas of breakdown, Erythema/edema, Exudate, Smell. Document which specific criteria are positive, not just "NERDS positive." Example: "NERDS screening: N positive (wound stalled ×2 weeks), E positive (exudate increased from scant to moderate), S positive (faint odor after cleaning). 3/5 positive - superficial infection suspected. MD notified."

Common Mistakes

Documenting Braden Total Without Subscale Scores

Weak: Braden 14.
Strong: Braden 14 (Sensory 3, Moisture 3, Activity 2, Mobility 2, Nutrition 2, Friction 2).

A Braden score of 14 can indicate very different clinical situations. Poor mobility combined with poor nutrition requires different interventions than issues related to moisture and friction. The subscales guide the selection of appropriate interventions.

Scoring based on the patient's usual status, not current state

Weak: Score Activity as 4 (walks frequently) based on the patient's usual ambulatory status, even though she has been bedfast for 3 days post-op.
Strong: Score Activity as 1 (bedfast) according to the patient's current functional status, with a note: "normally ambulatory per history; currently bedfast post-op day 3."

Braden measures risk RIGHT NOW, not the patient's baseline. A normally ambulatory patient who is currently bedfast has the pressure injury risk of a bedfast patient.

Wound Measurements Without Consistent Orientation

Weak: Wound measures 4 cm × 2 cm × 0.5 cm.
Strong: Wound measures 4 cm (head to foot) × 2 cm (side to side) × 0.5 cm depth. Undermining measures 0.3 cm at 3 o'clock to 6 o'clock.

Specifying orientation allows the next nurse to reproduce the measurement accurately. Consistency is essential for tracking whether the wound is improving or worsening.

Wound Bed Composition That Doesn't Total 100%

Weak: Wound bed 60% granulation, 50% slough.
Strong: Wound bed 60% granulation, 40% slough.

Wound bed percentages must total 100%. Any deviation represents a mathematical error that undermines the credibility of the assessment.

"Wound healing well" as the only documentation

Weak: Wound healing well.
Strong: Wound 3.5 × 1.8 × 0.3 cm (decreased from 4.2 × 2.1 × 0.5 cm last assessment). Wound bed 80% granulation, 20% slough. Periwound intact. Serous exudate, scant. No signs of infection per NERDS/STONEES.

"Healing well" is an opinion. The strong version is observable data. Opinions can't be trended or legally defended; measurements can.

Missing the Braden on Admission

Weak: Braden completed at end of shift as part of routine documentation.
Strong: Complete the Braden assessment within the admission timeframe (commonly within 2-8 hours of admission per institutional policy).

The Braden assessment serves as an admission evaluation at most institutions. A gap between admission and the first Braden score indicates a survey finding and poses a litigation risk, suggesting that the patient's pressure injury risk was not assessed promptly.

Mrs. WallaceAge 78 — Pneumonia; Hx CVA with R-sided weakness; Stage 2 pressure injury sacrum
fictional patient

Scenario

You're the day shift nurse on a medical floor. Mrs. Wallace was admitted yesterday from an extended care facility for pneumonia. She has a history of CVA with residual right-sided weakness and is chairfast at baseline. A Stage 2 sacral pressure injury was noted on the admission skin assessment. You are performing your 0800 Braden and wound assessment.

Chart Entry

0800 Braden Scale Assessment: Braden 11 (high risk) - Sensory 3, Moisture 3, Activity 2, Mobility 2, Nutrition 2, Friction 2.
• Sensory 3: responds to voice but cannot always communicate discomfort (right-sided neglect post-CVA)
• Moisture 3: episodes of incontinence overnight; skin moist twice during the last 8 hours
• Activity 2: chairfast, unable to bear weight independently
• Mobility 2: unable to reposition self; requires maximum assistance for turns
• Nutrition 2: ate 40% of breakfast; on an oral diet, poor appetite since admission
• Friction 2: requires moderate assistance for transfers; potential for sliding

Interventions per high-risk bundle: Q2h turning initiated. Pressure-redistributing mattress in place. Heel protectors applied bilaterally. Nutrition consult placed. Offloading sacrum during chair sitting. Next Braden reassessment at 2000 or with a change in status.

0800 Wound Assessment - Sacrum: Stage 2 pressure injury, sacral. 2.8 cm × 1.9 cm × 0.2 cm depth (head to foot × side to side). No undermining or tunneling. Wound bed 100% pink granulation - no slough, no eschar. Wound edges attached, no epibole. Periwound skin intact with minimal erythema (approximately 0.5 cm border). Scant serous exudate, no odor. Pain 2/10 at rest, 4/10 with repositioning - pre-medicated with acetaminophen 650mg PO at 0730. NERDS/STONEES: 0/5 NERDS criteria positive, 0/7 STONEES criteria positive. No signs of infection. Hydrocolloid dressing reapplied per wound care orders.

Annotations

Braden with clinical reasoning:
Each subscale includes the score AND the clinical observation that justifies it - makes the assessment defensible.
Score-to-intervention link:
The intervention section directly connects the Braden 11 (high risk) to the specific bundle implemented.
Complete wound assessment:
All 6 components documented: type/stage, measurements with orientation, bed composition, edges, exudate, and periwound.
NERDS/STONEES explicit:
Infection screening documented as specific criteria counts, not just "no infection."
Pain documented:
Wound-related pain at rest and with repositioning, plus pre-medication - demonstrates proactive pain management.

Pro Tips

  • Score the Braden at the End of Your Assessment, Not the Start: Once you complete your assessment, you will have all the necessary information: sensory status, moisture, activity level, mobility, nutritional intake, and friction risk. Scoring while you gather data can lead to errors.
  • Re-measure wounds the same way every time: Same tape position, same anatomical reference points, same head-to-foot and side-to-side orientation. Consistency is what makes measurements trendable. An inconsistent measurement technique makes it impossible to track healing.
  • Take wound photos if your institution allows them: A photo combined with measurements provides stronger documentation than measurements alone. Many EHRs now support wound photography. If yours does, use it; a picture with a measurement ruler in the frame represents the standard.
  • NERDS is Superficial, STONEES is Deep: These acronyms identify different types of wound infections. Mixing them up misidentifies the infection pattern and can lead to inappropriate treatment. NERDS (3/5 positive) indicates a superficial bacterial burden, while STONEES (3/7 positive) signifies a deep and surrounding tissue infection.
  • Braden 18 is still "mild risk," not "no risk": It's easy to dismiss a higher Braden score as not needing intervention. Even patients scoring 15-18 (mild risk) benefit from standard prevention measures: pressure-redistributing surfaces and regular repositioning. "Not at risk" doesn't start until 19 or above.

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