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198
Description
Form from HIS OpenVista
Keywords
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- 2/22/12 2/22/12 -
- 6/6/17 6/6/17 - Martin Dugas
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- 6/15/17 6/15/17 - Martin Dugas
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February 22, 2012
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BRADEN SCALE
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BRADEN SCALE
- StudyEvent: BRADEN SCALE
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item
SENSORY PERCEPTION: Ability to respond meaningfully to pressure.
text
CL Item
COMPLETELY LIMITED Unresponsive to painful stimuli, due to diminished level of consciousness or sedation, OR Limited ability to feel pain over most of body surface (SCORE=1) (1)
CL Item
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 1/2 the body (SCORE=2) (2)
CL Item
SLIGHTLY LIMITED Responds to verbal commands but cannot always communicate discomfort or need to be turned, OR Has some sensory impairment, which limits ability to feel pain or discomfort in 1 or 2 extremities. (SCORE=3) (3)
CL Item
NO IMPAIRMENT Responds to verbal command. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. (SCORE=4) (4)
Item
MOISTURE: The degree to which skin is exposed to moisture.
text
CL Item
CONSTANTLY MOIST Perspiration, urine, etc. keeps skin moist almost constantly. Dampness is detected every time a patient is moved or turned. (SCORE=1) (1)
CL Item
MOIST Skin is often but not always moist. Linen must be changed at least once a shift. (SCORE=2) (2)
CL Item
OCCASIONALLY MOIST Skin is occasionally moist requiring an extra linen change approximately once a day. (SCORE=3) (3)
CL Item
RARELY MOIST Skin is usually dry; linen requires changing only at routine intervals. (SCORE=4) (4)
CL Item
BEDFAST Confined to bed (SCORE=1) (1)
CL Item
CHAIR FAST Ability to walk is severly limited or nonexistant. Cannot bear weight and/or must be assisted into a chair or wheelchair. (SCORE=2) (2)
CL Item
WALKS OCCASIONALLY Walks occasionally during the day but for very short distances, with or without assistance. Spends majority of each shift in a bed or a chair.(SCORE=3) (3)
CL Item
WALKS FREQUENTLY Walks outside the room at least twice a day and inside the room at least once every 2 hours during waking hours. (SCORE=4) (4)
Item
MOBILITY: The ability to change and control position.
text
CL Item
COMPLETELY IMMOBILE Does not make even slight changes in body or extremity position without assistance. (SCORE=1) (1)
CL Item
VERY LIMITED Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. (SCORE=2) (2)
CL Item
SLIGHTLY LIMITED Makes frequent though slight changes in body or extremity position independently. (SCORE=3) (3)
CL Item
NO LIMITATIONS Makes major and frequent changes in position without assistance. (SCORE=4) (4)
CL Item
VERY POOR Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less 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 or IV for more than 5 days. (SCORE=1) (1)
CL Item
PROBABLY INADEQUATE: Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement, OR Receives less than optimal amount of liquid diet or tube feeding. (SCORE=2) (2)
CL Item
ADEQUATE Eats over 1/2 of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered, OR Is on a tube feeding or TPN regimen, which probably meets most of nutritional needs. (SCORE=3) (3)
CL Item
EXCELLENT Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation. (SCORE=4) (4)
CL Item
PROBLEM Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction. (SCORE=1) (1)
CL Item
POTENTIAL PROBLEM Moves feebly or requires minimum assistance. During a move, 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. (SCORE=2) (2)
CL Item
NO APPARENT PROBLEM Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during a move. Maintains good position in bed or chair at all times. (SCORE=3) (3)
TOTAL SCORE=
Item
text
PRESSURE ULCER PREVENTION GUIDELINES: THE SCORE IS 18 OR LESS IMPLEMENT THE PRESSURE ULCER PREVENTION PROTOCOL, AND REFER TO SPECIALTY BED PROTOCOL AND CHECKLIST TO DETERMINE WHICH PRESSURE REDUCING SURFACE IS INDICATED. 1. The Braden Scale will be used to assess all adult inpatients upon admission to the hospital, daily, after procedures requiring sedation, and upon transfer to another unit by the receiving unit. 2. Interventions to reduce pressure over bony prominences will be instituted on all patients whose Braden Scale is equal to or less than 18 as follows: a. Maintain proper body alignment. b. Maintain or enhance functional ability. c. Increase activity if not medically contraindicated. d. Establish a turning schedule so that two hours in a single position is the maximum duration. e. Maintain the head of bed elevation no more than 30 degrees. f. Position the body in 30-degree lateral position. g. If the head of the bed is elevated greater than 30 degrees for eating, watching television, limit the duration to less than 2 hours at a time. h. Off load heels with Heellifts or pillows placed lengthwise beneath legs i. Consider specialty bed or mattress replacement (see specialty bed protocol). j. Moisturize dry skin. k. Protect heels and elbows from friction by using transparent films, lubricants or padding. l. Monitor every 2 hours for incontinence. m. Use Aloe Vesta spray, follow by the application of Aloe Vesta Ointment when skin is soiled with urine or feces. n. Document interventions as applied. 3. Assess and document nutritional status on admission and order dietary screen when indicated. 4. Assist patients with meals as needed,ie.,open food containers, elevate head of bed, provide environment conductive to eating, and allow sufficient time and assistance for optimal intake. 5. Notify physician if fluid and nutritional intake is inadequate. 6. Provide and document education for pressure ulcer prevention for patients and family as follows: . Etiology of pressure ulcers . Inspection of skin . Protection of skin . Proper, safe cleansing techniques and agents . Reduction of pressure ulcer risk . Role of nutrition . Proper/correct positioning techniques . Proper use of pillows and/or other pressure reducing devices . Shin and other health status changes to be reported to health care professionals. THE SCORE IS 16 OR LESS IMPLEMENT THE PRESSURE ULCER PREVENTION GUIDELINES 1. The Braden Scale will be used to assess all adult inpatients upon admission to the hospital, every Monday, after procedures requiring sedation, and daily if there is an overall decline in the patient's health status or if the patient is on a pressure-reducing surface. 2. Interventions to reduce pressure over bony prominences will be instituted on all patients whose Braden Scale is equal to or less than 16 as follows: a. Maintain proper body alignment. b. Maintain or enhance functional ability. c. Increase activity if not medically contraindicated. d. Establish a turning schedule so that two hours in a single position is the maximum duration. e. Maintain the head of bed elevation no more than 30 degrees. f. Position the body in 30-degree lateral position. g. If the head of the bed is elevated greater than 30 degrees for eating,watching television, limit the duration to less than 2 hours at a time. h. Off load heels with Heellifts or pillows placed lengthwise beneath legs. i. Consider specialty bed or mattress replacement (see specialty bed protocol). j. Moisturize dry skin. k. Protect heels and elbows from friction by using transparent films, lubricants or padding. l. Monitor every 2 hours for incontinence. m. Use Aloe Vesta spray, follow by the application of Aloe Vesta Ointment when skin is soiled with urine or feces. n. Document interventions as applied. 3. Assess and document nutritional status on admission and order dietary screen when indicated. 4. Assist patients with meals as needed,ie.,open food containers, elevate head of bed, provide environment conductive to eating, and allow sufficient time and assistance for optimal intake. 5. Notify physician if fluid and nutritional intake is inadequate. 6. Provide and document education for pressure ulcer prevention for patients and family as follows: . Etiology of pressure ulcers . Inspection of skin . Protection of skin . Proper, safe cleansing techniques and agents . Reduction of pressure ulcer risk . Role of nutrition . Proper/correct positioning techniques . Proper use of pillows and/or other pressure reducing devices . Shin and other health status changes to be reported to health care professionals.
Item
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