The Braden Scale runs 6 to 23, and the counterintuitive part is that a lower score means higher risk. Score the six subscales and read them as an intervention list rather than a number, then stage a wound by the deepest tissue you can actually see — and practise finding a Stage 1 in darkly pigmented skin, where redness is the wrong thing to look for.
Braden Scale for Predicting Pressure Sore Risk
Score on admission, then per policy — commonly every 24 hours on medical-surgical units and every shift in critical care — and again with any change in condition.
Anything the score cannot see?
Stage by the deepest visible tissue
Staging describes anatomy, not how bad it looks. If you cannot see the base, you cannot stage it — and unstageable is a real answer, not an admission of failure.
Special cases
The bedsideYour patient has darkly pigmented skin. You turn her and the sacral area is not obviously red — but she winces when you touch it. Patients with darker skin are demonstrably more likely to present at Stage 3 or 4, because Stage 1 was never seen.
Which cues will you use?
Where do you look for these?
Prevention orders you will put in place
Score the six subscalesFive score 1–4; friction and shear scores 1–3.
6 very high121823 no risk
Lower is worse. 19–23 no risk · 15–18 mild · 13–14 moderate · 10–12 high · 9 or below very high. Clinical judgment overrides the number upward, never downward.
Answer the questions on the leftTwo questions settle most staging disputes.
Is the skin intact? If yes, you are choosing between Stage 1 and deep tissue pressure injury. Can I see fat? If yes, it is at least Stage 3. If you cannot see the base at all, it is unstageable.
Do not let redness be your only cluePick your cues, your sites and your prevention orders.
LifespanInfants have a thin stratum corneum and a proportionally large occiput that becomes the number-one pressure site, plus near-total device-related risk from probes and tubing. Children from about 21 days to 8 years are scored with the Braden Q, not the adult Braden. In pregnancy, position in left lateral tilt to avoid aortocaval compression. Older adults lose dermal thickness, subcutaneous fat over the trochanters and sacrum, elastin and sebum — so skin tears from tape and shear become their own injury category, turgor is unreliable, and you use silicone or paper tape and lift rather than drag, every single time.