| ENTRY SPECIFICATION |
{"name": "BRADEN SCALE",
Responds only to painful stimuli. Cannot communicate discomfort except by
slight changes in body or extremity position independently. NO LIMITATION: Makes
major and frequent changes in position without assistance.",
"columns": 1,
"choices":[
{"id": "c1235", "text": "1. Completely immobile.", "quickKey": 1},
{"id": "c1204", "text": "2. Very limited.", "quickKey": 2},
{"id": "c1205", "text": "3. Slightly limited.", "quickKey": 3},
{"id": "c1236", "text": "4. No limitation.", "quickKey": 4}
]},
{"id": "i890", "type": "IntroText",
moaning or restlessness or has a sensory impairment that limits the ability to
"text": "Terms used in next item. VERY POOR: Never eats a complete meal. Rarely eats more
than half of any food offered. Eats two servings or less of protein (meat or
dairy products) per day. Takes fluids poorly. Doesn't take a liquid dietary
supplement or is N.P.O. or maintained on clear liquids or I.V. solution for more
than 5 days. PROBABLY INADEQUATE: Rarely eats a complete meal and generally eats
only about half of any food offered. Eats three servings of protein (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 four servings of protein (meat or dairy products) per
day. Occasionally will refuse a meal, but will usually take a supplement when
feel pain or discomfort over half of body. SLIGHTLY LIMITED: Responds to verbal
offered or is on a tube feeding or total parenteral nutrition regime that
probably meets most of nutritional needs. EXCELLENT: Eats most every meal. Never
refuses a meal. Eats four or more servings of protein (meat or dairy products)
per day. Occasionally eats between meals. Doesn't require supplementations."
},
{"id": "q5431", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": " Nutrition -- usual food intake patterns",
"intro": "Terms used in next item. VERY POOR: Never eats a complete meal. Rarely eats more
than half of any food offered. Eats two servings or less of protein (meat or
dairy products) per day. Takes fluids poorly. Doesn't take a liquid dietary
commands, but cannot always communicate discomfort of the need to be turned or
supplement or is N.P.O. or maintained on clear liquids or I.V. solution for more
than 5 days. PROBABLY INADEQUATE: Rarely eats a complete meal and generally eats
only about half of any food offered. Eats three servings of protein (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 four servings of protein (meat or 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 regime that
probably meets most of nutritional needs. EXCELLENT: Eats most every meal. Never
refuses a meal. Eats four or more servings of protein (meat or dairy products)
has some sensory impairment that limits ability to feel pain or discomfort in
per day. Occasionally eats between meals. Doesn't require supplementations.",
"columns": 1,
"choices":[
{"id": "c1237", "text": "1. Very poor.", "quickKey": 1},
{"id": "c1238", "text": "2. Probably inadequate.", "quickKey": 2},
{"id": "c1239", "text": "3. Adequate.", "quickKey": 3},
{"id": "c1240", "text": "4. Excellent.", "quickKey": 4}
]},
{"id": "i790", "type": "IntroText",
"text": "Terms used in next item. PROBLEM: Requires moderate to maximum assistance in
one or two extremities. NO IMPAIRMENT: Responds to verbal commands. Has no
moving. Complete lifting without sliding against sheets is impossible.
Frequently slides down in bed or chair, requiring frequent respositioning with
maximum assistance. Spasticity, contractures, or agitation leads to almost
constant friction. 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. NO APPARENT PROBLEM: Moves
in bed and in chair independently and has sufficient muscle strength to lift up
completely during move. Maintains good position in bed or chair."
},
sensory deficit that would limit ability to feel pain or voice pain or
{"id": "q5432", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": " Friction and shear",
"intro": "Terms used in next 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 respositioning with
maximum assistance. Spasticity, contractures, or agitation leads to almost
constant friction. 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. NO APPARENT PROBLEM: Moves
discomfort."
in bed and in chair independently and has sufficient muscle strength to lift up
completely during move. Maintains good position in bed or chair.",
"columns": 1,
"choices":[
{"id": "c1241", "text": "1. Problem.", "quickKey": 1},
{"id": "c1242", "text": "2. Potential problem.", "quickKey": 2},
{"id": "c1243", "text": "3. No apparent problem.", "quickKey": 3}
]}]
}
},
{"id": "q5427", "type": "ChoiceQuestion", "required": false, "inline": false,
"copyright": "Copyright Barbara Braden & Nancy Bergstrom, 1988",
"text": " Sensory perception -- ability to respond meaningfully to pressure-related
discomfort",
"intro": "Terms used in the next item. COMPLETELY LIMITED: Unresponsive (doesn't moan,
flinch, or gasp) to painful stimuli due to diminished level of consciousness or
sedation or limited ability to feel pain over most of body. VERY LIMITED:
Responds only to painful stimuli. Cannot communicate discomfort except by
moaning or restlessness or has a sensory impairment that limits the ability to
feel pain or discomfort over half of body. SLIGHTLY LIMITED: Responds to verbal
commands, but cannot always communicate discomfort of the need to be turned or
has some sensory impairment that limits ability to feel pain or discomfort in
"restartDays": 2,
one or two extremities. NO IMPAIRMENT: Responds to verbal commands. Has no
sensory deficit that would limit ability to feel pain or voice pain or
discomfort.",
"columns": 1,
"choices":[
{"id": "c1203", "text": "1. Completely limited.", "quickKey": 1},
{"id": "c1204", "text": "2. Very limited.", "quickKey": 2},
{"id": "c1205", "text": "3. Slightly limited.", "quickKey": 3},
{"id": "c1206", "text": "4. No impairment.", "quickKey": 4}
]},
"printTitle": "Braden Scale for Predicting Pressure Ulcer Risk",
{"id": "i787", "type": "IntroText",
"text": "Terms used in next item. CONSTANTLY MOIST: Skin is kept moist almost constantly
by perspiration, urine, etc. Dampness is detected every time 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, requiring
an extra linen change about once a day. RARELY MOIST: Skin is usually dry;
linen requires changing at routine intervals."
},
{"id": "q5428", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": " Moisture -- degree to which skin is exposed to moisture",
"content":[
"intro": "Terms used in next item. CONSTANTLY MOIST: Skin is kept moist almost constantly
by perspiration, urine, etc. Dampness is detected every time 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, requiring
an extra linen change about once a day. RARELY MOIST: Skin is usually dry;
linen requires changing at routine intervals.",
"columns": 1,
"choices":[
{"id": "c1234", "text": "1. Constantly moist.", "quickKey": 1},
{"id": "c1227", "text": "2. Very moist.", "quickKey": 2},
{"id": "i708", "type": "IntroText",
{"id": "c1228", "text": "3. Occasionally moist.", "quickKey": 3},
{"id": "c1229", "text": "4. Rarely moist.", "quickKey": 4}
]},
{"id": "i788", "type": "IntroText",
"text": "Terms used in next item. BEDFAST: Confined to bed. CHAIR FAST: Ability to walk
severely limited or nonexistent. Cannot bear own weight or must be assisted into
chair or wheelchair. WALKS OCCASIONALLY: Walks occasionally during day but for
very short distances, with or without assistance. Spends most of each shift in
bed or chair. WALKS FREQUENTLY: Walks outside room at least twice a day and
inside room at least once every 2 hours during waking hours."
"text": "Terms used in the next item. COMPLETELY LIMITED: Unresponsive (doesn't moan,
},
{"id": "q5429", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": " Activity -- ability to change and control body position",
"intro": "Terms used in next item. BEDFAST: Confined to bed. CHAIR FAST: Ability to walk
severely limited or nonexistent. Cannot bear own weight or must be assisted into
chair or wheelchair. WALKS OCCASIONALLY: Walks occasionally during day but for
very short distances, with or without assistance. Spends most of each shift in
bed or chair. WALKS FREQUENTLY: Walks outside room at least twice a day and
inside room at least once every 2 hours during waking hours.",
"columns": 1,
flinch, or gasp) to painful stimuli due to diminished level of consciousness or
"choices":[
{"id": "c1230", "text": "1. Bedfast.", "quickKey": 1},
{"id": "c1231", "text": "2. Chair fast.", "quickKey": 2},
{"id": "c1232", "text": "3. Walks occasionally.", "quickKey": 3},
{"id": "c1233", "text": "4. Walks frequently.", "quickKey": 4}
]},
{"id": "i789", "type": "IntroText",
"text": "Terms used in next item. COMPLETLY IMMOBILE: Doesn't make even slight changes in
body or extremity position without assistance. VERY LIMITED: Makes occasional
slight changes in body or extremity position but can't make frequent or
sedation or limited ability to feel pain over most of body. VERY LIMITED:
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."
},
{"id": "q5430", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": " Mobility -- ability to change and control body position",
"intro": "Terms used in next item. COMPLETLY IMMOBILE: Doesn't make even slight changes in
body or extremity position without assistance. VERY LIMITED: Makes occasional
slight changes in body or extremity position but can't make frequent or
significant changes independently. SLIGHTLY LIMITED: Makes frequent though
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