Name | Value |
---|---|
INSTRUMENT | BRADEN SCALE |
LAST UPDATE | 2022-04-08 08:14:07 |
ENTRY CHECKSUM | 726014280 |
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 |