ID

22898

Description

Kozier, Barbara, Glenora Erb, Shirlee Snyder, and Audrey Berman. Fundamentals of Nursing: Concepts, Process, and Practice. 8th ed. Upper Saddle Riveer, NJ: Pearson Education, 2008. 905-907.

Keywords

Versions (5)
  1. 2/22/12 2/22/12 -
  2. 6/6/17 6/6/17 - Martin Dugas
  3. 6/7/17 6/7/17 - Martin Dugas
  4. 6/15/17 6/15/17 - Martin Dugas
  5. 6/15/17 6/15/17 - Martin Dugas
Uploaded on

June 15, 2017

DOI

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License

Creative Commons BY-NC 3.0
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BRADEN SCALE

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BRADEN SCALE

1 forms  
  1. StudyEvent: BRADEN SCALE
    1. BRADEN SCALE
BRADEN SCALE Data
Description

BRADEN SCALE Data

Alias
UMLS CUI-1
C1446249
SENSORY PERCEPTION: Ability to respond meaningfully to pressure.
Description

sensory score for skin ulcer risk assessment using Braden scale

Data type

integer

Alias
UMLS CUI [1]
C2171315
MOISTURE: The degree to which skin is exposed to moisture.
Description

moisture score for skin ulcer risk assessment using Braden scale

Data type

integer

Alias
UMLS CUI [1]
C2171313
ACTIVITY: Degree of physical activity.
Description

activity score for skin ulcer risk assessment using Braden scale

Data type

integer

Alias
UMLS CUI [1]
C2171311
MOBILITY: The ability to change and control position.
Description

mobility score for skin ulcer risk assessment using Braden scale

Data type

integer

Alias
UMLS CUI [1]
C2171312
NUTRITION: Usual food intake pattern
Description

nutrition score for skin ulcer risk assessment using Braden scale

Data type

integer

Alias
UMLS CUI [1]
C2171314
FRICTION AND SHEAR:
Description

friction and shear score for skin ulcer risk assessment using Braden scale

Data type

integer

Alias
UMLS CUI [1]
C2171310
TOTAL BRADEN SCORE
Description

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.

Data type

integer

Alias
UMLS CUI [1]
C2171309
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Similar models

BRADEN SCALE

1 forms
  1. StudyEvent: BRADEN SCALE
    1. BRADEN SCALE
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
BRADEN SCALE Data
C1446249 (UMLS CUI-1)
Item
SENSORY PERCEPTION: Ability to respond meaningfully to pressure.
integer
C2171315 (UMLS CUI [1])
CL.1
Code List
SENSORY PERCEPTION: Ability to respond meaningfully to pressure.
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 (1)
C3693312 (UMLS CUI-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 (2)
C3693309 (UMLS CUI-1)
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 (3)
C3693310 (UMLS CUI-1)
CL Item
NO IMPAIRMENT. Responds to verbal command. Has no sensory deficit which would limit ability to feel or voice pain or discomfort (4)
C3693311 (UMLS CUI-1)
Item
MOISTURE: The degree to which skin is exposed to moisture.
integer
C2171313 (UMLS CUI [1])
CL.2
Code List
MOISTURE: The degree to which skin is exposed to moisture.
CL Item
CONSTANTLY MOIST. Perspiration, urine, etc. keeps skin moist almost constantly. Dampness is detected every time a patient is moved or turned (1)
C3693320 (UMLS CUI-1)
CL Item
MOIST. Skin is often but not always moist. Linen must be changed at least once a shift (2)
C3693317 (UMLS CUI-1)
CL Item
OCCASIONALLY MOIST Skin is occasionally moist requiring an extra linen change approximately once a day (3)
C3693319 (UMLS CUI-1)
CL Item
RARELY MOIST Skin is usually dry; linen requires changing only at routine intervals (4)
C3693318 (UMLS CUI-1)
Item
ACTIVITY: Degree of physical activity.
integer
C2171311 (UMLS CUI [1])
CL.3
Code List
ACTIVITY: Degree of physical activity.
CL Item
BEDFAST. Confined to bed (1)
C3693331 (UMLS CUI-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 (2)
C3693330 (UMLS CUI-1)
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 (3)
C3693328 (UMLS CUI-1)
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 (4)
C3693329 (UMLS CUI-1)
Item
MOBILITY: The ability to change and control position.
integer
C2171312 (UMLS CUI [1])
CL.4
Code List
MOBILITY: The ability to change and control position.
CL Item
COMPLETELY IMMOBILE. Does not make even slight changes in body or extremity position without assistance (1)
C3693324 (UMLS CUI-1)
CL Item
VERY LIMITED. Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently (2)
C3693321 (UMLS CUI-1)
CL Item
SLIGHTLY LIMITED. Makes frequent though slight changes in body or extremity position independently (3)
C3693322 (UMLS CUI-1)
CL Item
NO LIMITATIONS. Makes major and frequent changes in position without assistance (4)
C3693323 (UMLS CUI-1)
Item
NUTRITION: Usual food intake pattern
integer
C2171314 (UMLS CUI [1])
CL.5
Code List
NUTRITION: Usual food intake pattern
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. (1)
C3693313 (UMLS CUI-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. (2)
C3693314 (UMLS CUI-1)
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. (3)
C3693316 (UMLS CUI-1)
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. (4)
C3693315 (UMLS CUI-1)
Item
FRICTION AND SHEAR:
integer
C2171310 (UMLS CUI [1])
CL.6
Code List
FRICTION AND SHEAR:
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. (1)
C3693325 (UMLS CUI-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. (2)
C3693326 (UMLS CUI-1)
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. (3)
C3693327 (UMLS CUI-1)
Braden score
Item
TOTAL BRADEN SCORE
integer
C2171309 (UMLS CUI [1])
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