ARCHETYPE Braden scale (openEHR-EHR-OBSERVATION.braden_scale.v1)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.braden_scale.v1
ConceptBraden scale
DescriptionThe Braden Scale for Predicting Pressure Sore Risk is a tool used to assess the risk of pressure ulcer development in adults and children over the age of five years.
UseUse to assess risk of pressure ulcer development in an adult population or for children aged 5 and over, in both hospital and community settings. There are two commonly used variants - one intended for hospital use and the other for home use. They differ only in the description of the Moisture data element where the frequency of bedding change is described as "three times per 24 hours" for home use or "once per shift" for hospital use. As these two descriptions have the same essential meaning, this archetype has used the most generally applicable wording, based on the home use variant. While openEHR archetypes are all freely available under an open license, the specific content of this Braden Scale archetype is copyright protected. Any use of this archetype within implementations must be in compliance with the terms established by the copyright owners. Copyright statement: Barbara Braden and Nancy Bergstrom, 1988 All rights reserved Copyright information: http://bradenscale.com/copyright.htm.
MisuseNot to be used unless the terms of copyright have been observed -see http://bradenscale.com/copyright.htm for details. The Braden Scale should not be used for children between 21 days and 5 years. Use an archetype specifically designed for the Paediatric Braden Scale. The Braden Scale should not be used for children aged less than 21 days. Use an archetype specifically designed for the Neonatal Braden Scale.
PurposeTo record information about factors used to assess the risk of pressure ulcer development, and the total Braden Scale score.
ReferencesBergstrom, N., Braden, B., Laguzza, A. & Holman, A. (1987). The Braden Scale for predicting pressure sore risk. Nursing Research. 36(4), 205-210.

Braden, B. J. & Blanchard, S. (2007). Risk assessment in pressure ulcer prevention. In D. L. Krasner, G. T. Rodeheaver, & R. G. Sibbald (Eds.), Chronic Wound Care: A Clinical Source Book for Healthcare Professionals (4th ed.). Wayne PA: HMP Communications

Ayello, E.A. & Braden, B. (2002) How and why to do pressure ulcer risk assessment. Advances in Wound Care, 15 (3), 125-131.

Prevention Plus - Home of the Braden Scale [Internet]. [date unknown];[cited 2011 Aug 1] Available from: http://bradenscale.com/index.htm

Braden Scale for Predicting Pressure Score Risk [Internet]. [date unknown];[cited 2011 Aug 1] Available from: http://bradenscale.com/images/bradenscale.pdf

Braden Scale for Predicting Pressure Score Risk in Home Care [Internet]. [date unknown];[cited 2011 Aug 1] Available from: http://bradenscale.com/images/bschome.pdf

Norwegian translation by Bjøro (1998), from Metode for å redusere forekomst av trykksår ved norske sykehjem, Sintef (2007). https://www.sintef.no/globalassets/upload/helse/levekar-og-tjenester/forebygging-av-trykksar-i-sykehjem.pdf
Copyright© openEHR Foundation
AuthorsAuthor name: Ian McNicoll
Organisation: Ocean Informatics, UK
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 2011-08-01
Other Details LanguageAuthor name: Ian McNicoll
Organisation: Ocean Informatics, UK
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 2011-08-01
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/, custodian_organisation=openEHR Foundation, references=Bergstrom, N., Braden, B., Laguzza, A. & Holman, A. (1987). The Braden Scale for predicting pressure sore risk. Nursing Research. 36(4), 205-210. Braden, B. J. & Blanchard, S. (2007). Risk assessment in pressure ulcer prevention. In D. L. Krasner, G. T. Rodeheaver, & R. G. Sibbald (Eds.), Chronic Wound Care: A Clinical Source Book for Healthcare Professionals (4th ed.). Wayne PA: HMP Communications Ayello, E.A. & Braden, B. (2002) How and why to do pressure ulcer risk assessment. Advances in Wound Care, 15 (3), 125-131. Prevention Plus - Home of the Braden Scale [Internet]. [date unknown];[cited 2011 Aug 1] Available from: http://bradenscale.com/index.htm Braden Scale for Predicting Pressure Score Risk [Internet]. [date unknown];[cited 2011 Aug 1] Available from: http://bradenscale.com/images/bradenscale.pdf Braden Scale for Predicting Pressure Score Risk in Home Care [Internet]. [date unknown];[cited 2011 Aug 1] Available from: http://bradenscale.com/images/bschome.pdf Norwegian translation by Bjøro (1998), from Metode for å redusere forekomst av trykksår ved norske sykehjem, Sintef (2007). https://www.sintef.no/globalassets/upload/helse/levekar-og-tjenester/forebygging-av-trykksar-i-sykehjem.pdf, current_contact=Ian McNicoll, freshEHR Clinical Informatics, UK, ian@freshehr.com, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=935B41CA3BE85FF30CB782AC471244E1, build_uid=51e25abc-6368-4c0c-a743-3fb00a4a63ee, ip_acknowledgements=This artefact includes content from SNOMED Clinical Terms® (SNOMED CT®) which is copyrighted material of the International Health Terminology Standards Development Organisation (IHTSDO). Where an implementation of this artefact makes use of SNOMED CT content, the implementer must have the appropriate SNOMED CT Affiliate license - for more information contact http://www.snomed.org/snomed-ct/get-snomedct or info@snomed.org., revision=1.2.0}
Keywordspressure, sore, ulcer, Braden, adult, score, assessment
Lifecyclepublished
UID3eb327e3-8913-411e-a968-db15efdb3838
Language useden
Citeable Identifier1013.1.1014
Revision Number1.2.0
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=[SNOMED-CT::413139004 | Braden assessment scale (assessment scale)], archetypeConceptDescription=The Braden Scale for Predicting Pressure Sore Risk is a tool used to assess the risk of pressure ulcer development in adults and children over the age of five years., archetypeConceptComment=null, otherContributors=Vebjørn Arntzen, Oslo universitetssykehus HF, Norway (Nasjonal IKT redaktør)
Silje Ljosland Bakke, National ICT Norway, Norway (openEHR Editor)
Lars Bitsch-Larsen, Haukeland University Hospital, Bergen, Norway
Karen Bjøro, Norsk Sykepleierforbund, Norway
Rui Coutinho, Centro Hospitalar do Porto, Portugal
Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway
Heather Grain, Llewelyn Grain Informatics, Australia
Øygunn Leite Kallevik, Helse Bergen, Norway
Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Siv Marie Lien, DIPS ASA, Norway
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor)
Lars Morgan Karlsen, DIPS ASA, Norway
Knut Nesheim, Helse Bergen, Norway
Mona Oppedal, Helse Bergen, Norway
Andrej Orel, Marand d.o.o., Slovenia
Rune Pedersen, Universitetssykehuset i Nord Norge, Norway
Navin Ramachandran, NHS, United Kingdom
Tanja Riise, Nasjonal IKT HF, Norway
Line Sæle, Nasjonal IKT HF, Norway
John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør), originalLanguage=en, translators=Finnish: Vesa Peltola, Tieto Finland
Spanish (Argentina): Alan March, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina., alandmarch@gmail.com
Norwegian Bokmål: John Tore Valand og Silje Ljosland Bakke, Helse Bergen og Nasjonal IKT
Portuguese (Brazil): Osmeire Chamelette Sanzovo, Hospital Sírio Libanês - SP, osmeire.acsanzovo@hsl.org.br
Chinese (PRC): Lin Zhang, Taikang Insurance Group, linforest@163.com, Confused
, subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={identities=[], other_participations=[], credentials=[], description=[], relationships=[], ism_transition=[], activities=[], items=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=ELEMENT, level=4, text=Sensory perception, description=Ability to respond meaningfully to pressure-related discomfort., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=[LOINC::38222-6 | Sensory perception Braden scale], values=1: Completely limited [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.]
[LOINC::LA9603-7]

2: 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 of body.]
[LOINC::LA9605-4]

3: Slightly limited [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 1 or 2 extremities.]
[LOINC::LA9605-2]

4: No impairment [Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.]
[LOINC::LA9606-0]

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Moisture, description=Degree to which skin is exposed to moisture., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=[LOINC::38229-1 | Moisture exposure Braden scale], values=1: Constantly moist [Skin is kept moist almost constantly by perspiration, urine etc. Dampness is detected every time patient is moved or turned.]
[LOINC::LA9607-8]

2: Very moist [Skin is often, but not always moist. Linen must be changed as often as 3 times in 24 hours.]
[LOINC::LA9608-6]

3: Occasionally moist [Skin is occasionally moist, requiring an extra linen change approximately once a day.]
[LOINC::LA9609-4]

4: Rarely moist [Skin is usually dry, linen only requires changing at routine intervals.]
[LOINC::LA9610-2]

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Activity, description=Degree of physical ability., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=[LOINC::38223-4 | Physical activity Braden scale], values=1: Bedfast [Confined to bed.]
[LOINC::LA6742-6]

2: Chairfast [Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.]
[LOINC::LA9611-0]

3: Walks occasionally [Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair. OR spends majority of each day at home in bed or chair.]
[LOINC::LA9612-8]

4: Walks frequently [Walks outside room at least twice a day and inside room at least once every two hours during waking hours.]
[LOINC::LA9613-6]

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0019], code=at0019, itemType=ELEMENT, level=4, text=Mobility, description=Ability to change and control body position., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=[LOINC::38224-2 | Physical mobility Braden scale], values=1: Completely immobile [Does not make even slight changes in body or extremity position without assistance.]
[LOINC::LA9614-4]

2: Very limited [Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.]
3: Slightly limited [Makes frequent though slight changes in body or extremity position independently.]
4: No limitation [Makes major and frequent changes in position without assistance.]
[LOINC::LA120-8]

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[LOINC::LA9615-1]

2: 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 optimum amount of liquid diet or tube feeding.]
[LOINC::LA9616-9]

3: Adequate [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 which probably meets most of their nutritional needs.]
[LOINC::LA8913-1]

4: 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.]
[LOINC::LA9206-9]

, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0021], code=at0021, itemType=ELEMENT, level=4, text=Friction and shear, description=Friction occurs when skin moves against support surfaces. Shear occurs when skin and adjacent bony surface slide across one another., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=[LOINC::38226-7 | Friction and shear Braden scale], values=1: 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.]
[LOINC::LA9617-7]

2: 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.]
[LOINC::LA9618-5]

3: 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.]
[LOINC::LA9619-3]

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[SNOMED-CT::443428004 | Braden pressure sore risk score (observable entity)], values=min: >=6; max: <=23

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