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.
Braden Scale Friction and Shear 2 Potential Problem
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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
Never eats a complete meal. Rarely eats more than 1/2 of any food offered. Eats 2 servings or less of protein per day. Takes fluids poorly, does not take a liquid supplement. OR is NPO maintained on clear liquids or IV's for more than 5 days
Rarely eats a complete meal and generally eats only about 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 optimum amount of liquid.
Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered. OR is on a tube feeding or TPN regimen.
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 supplements
Unresponsive (does not moan, flinch or grasp) to painful stimuli, due to diminished level of consciousness or sedation. OR limited ability to feel pain over most of body
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 of the body
Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR has some sensory impairment which limits ability to feel pain or discomfort in one or two extremities.
Ask \"Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?\"
Ask \"Does your head feel different? Does it feel like there is a band around your head? Do not rate for dizziness or lightheadedness.\" Otherwise, rate severity.
How resident puts on, fastens and takes off all items of clothing, including donning/removing a prosthesis or TED hose. Dressing includes putting on and changing pajamas and housedresses.
How resident puts on, fastens and takes off all items of clothing, including donning/removing a prosthesis or TED hose. Dressing includes putting on and changing pajamas and housedresses.
How resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. Includes intakes of nourishment by other means (eg. Tube feeding, total parenteral nutrition, IV fluids administered for nutrition or hydration)
How resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. Includes intakes of nourishment by other means (eg. Tube feeding, total parenteral nutrition, IV fluids administered for nutrition or hydration)
How resident moves to and returns from off-unit locations (eg. areas set aside for dining, activities, treatments). If facility only has 1 floor, how resident moves to/from distant areas on floor. If in wheelchair, self-sufficiency once in chair
How resident moves to and returns from off-unit locations (eg. areas set aside for dining, activities, treatments). If facility only has 1 floor, how resident moves to/from distant areas on floor. If in wheelchair, self-sufficiency once in chair
How resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers)
How resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers)
How resident uses the toilet room, commode, bedpan or urinal; transfers on/off toilet; cleanses after elimination; changes pad; manages ostomy or catheter; adjusts clothes. Do not include emptying bedpan, urinal, commode, catheter or ostomy bag.
How resident uses the toilet room, commode, bedpan or urinal; transfers on/off toilet; cleanses after elimination; changes pad; manages ostomy or catheter; adjusts clothes. Do not include emptying bedpan, urinal, commode, catheter or ostomy bag.
Use Scale 2 if target range is 88-92%, e.g, in hypercapnic respiratory failure (usually due to COPD), *ONLY use Scale 2 under the direction of a qualified clinician.
JH- HLM: Johns Hopkins Highest Level of Mobility Scale. Used by permission from the authors under a Creative Commons Attribution-Noncommercial-NoDeivs 4.0 International License. http://bit.ly/HopkinsAMP
Braden Scale Activity - degree of physical activity
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1. Bedfast: Confined to bed 2. Chairfast: Ability to walk severely limited or non-existent. 3. Walks Occasionally: Walks occasionally during day, but for very short distances, with or without assistance. 4. Walks Frequently: Walks outside room.
1. Problem: Requires moderate to maximum assistance in moving. 2 Potential Problem: Moves feebly or requires minimum assistance.3 No Apparent Problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely