ARCHETYPE Neonatal Skin Risk Assessment Scale (NSRAS) (openEHR-EHR-OBSERVATION.neonatal_skin_risk_assessment.v0)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.neonatal_skin_risk_assessment.v0
ConceptNeonatal Skin Risk Assessment Scale (NSRAS)
DescriptionA clinical assessment for neonates at risk for skin breakdown, based on the Braden Scale used in adults.
UseUse record details of a clinical assessment of neonates at risk of skin breakdown or pressure sore development. It should be noted that although the purpose of the scale is similar to that of the adult Braden Scale and Braden-Q scale for older children, the scoring methodology is completely different, particularly that a high score is associated with high risk, the opposite from these other Braden scales where a low score equates to high risk. The Neonatal Skin Risk Assessment Scale (NSRAS) should only be used to assess nenoates under 21 days of age.
MisuseNot to be used for pressure sore risk assessment in children aged over 21 days. Use OBSERVATION.braden_scale-q for children between 21 days and 5 years of age. Use OBSERVATION.braden_scale for children over 5 years of age and adults.
PurposeTo record details of a clinical assessment of neonates at risk of skin breakdown or pressure sore development.
ReferencesHuffines B, Logsdon MC. The neonatal skin risk assessment scale for predicting skin breakdown in neonates. Issues in Comprehensive Pediatric Nursing 1997;20(2):103-114.
Copyright© openEHR Foundation
AuthorsAuthor name: Dr Ian McNicoll
Organisation: freshEHR Clinical Informatics, UK
Email: ian@freshehr.com
Date originally authored: 2011-08-08
Other Details LanguageAuthor name: Dr Ian McNicoll
Organisation: freshEHR Clinical Informatics, UK
Email: ian@freshehr.com
Date originally authored: 2011-08-08
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, references=Huffines B, Logsdon MC. The neonatal skin risk assessment scale for predicting skin breakdown in neonates. Issues in Comprehensive Pediatric Nursing 1997;20(2):103-114., current_contact=Dr Ian McNicoll, freshEHR Informatics, UK, ian@freshehr.com, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=F69B1DD5EE61A5E3763D8BE112F526BA, build_uid=95daac4d-9012-4cf6-b740-270228d0c3ff, revision=0.0.1-alpha}
Keywordsbraden, neonate, score, skin, pressure, ulcer, sore
Lifecyclein_development
UIDab4e9399-9ba3-4601-a9d0-1d20db1e5f2a
Language useden
Citeable Identifier1013.1.1035
Revision Number0.0.1-alpha
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Heather Leslie, Atomica Informatics, Australia (openEHR Editor)
Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor), originalLanguage=en, translators=, 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[at0011], code=at0011, itemType=ELEMENT, level=4, text=General physical condition, description=An assessment of general condition, based on gestational age., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=1: Best [Gestational Age > 38 Weeks To Posterm.]
2: Good [Gestational Age > 33 Weeks But < 38 weeks.]
3: Poor [Gestational Age > 28 Weeks But < 33 weeks.]
4: Very poor [Gestational Age > 28 Weeks But < 33 weeks.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=4, text=Moisture, description=The degree to which the infant's 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=null, values=1: Rarely moist [Skin is usually dry, linen requires changing only every 24 hours.]
2: Occasionally moist [Skin is occasionally moist/damp. Requiring an extra linen change approximately once a day.]
3: Moist [Skin is often but not always moist/damp; linen must be changed at least once a shift.]
4: Constantly moist [Skin is moist/damp every time infant is moved or turned.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0006], code=at0006, itemType=ELEMENT, level=4, text=Nutrition, description=The usual food intake of the neonate., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=1: Excellent [Bottlehreastfeeds every meal which meets nutritional needs for growth.]
2: Adequate [Is on tube feedings which meet nutritional needs for growth.]
3: Inadequate [Receives less than optimum amount of liquid diet for growth (formula/breast milk) and supplemented with intravenous fluids.]
4: Very poor [NPO on intravenous fluids.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0007], code=at0007, itemType=ELEMENT, level=4, text=Activity, description=The amount of physical activity of the neonate., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=1: Unlimited [In an open crib.]
2: Slightly limited [In a double walled isolette.]
3: Limited bed-bound [In a radiant warmer without a clear plastic “saran” tent.]
4: Completely bed-bound [In a radiant warmer with a clear plastic “saran” tent.]
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2: Slightly limited [Makes frequent though slight changes in body or extremity position independently.]
3: Very limited [Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.]
4: Completely immobile [Does not make even slight changes in body or extremity position without assistance (e.g., Pavulon).]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0009], code=at0009, itemType=ELEMENT, level=4, text=Mental status, description=An evaluation of the mental status or sensory preception of the neonate., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=1: No impairment [Alert and active.]
2: Slightly limited [Lethargic.]
3: Very limited [Responds only to painful stimuli (flinches, grasps, moans, increased blood pressure or heart rate).]
4: Completely limited [Unresponsive (does not flinch, grasp, moan, increase blood pressure, or heart rate) to painful stimuli due to diminished level of consciousness or sedation.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Total score, description=The sum of all sub-scores., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=2; max: <=24

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1: At risk - Total score 13 or over [The neonate is not at risk of developing a pressure ulcer.]
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4: Very poor [Gestational Age > 28 Weeks But < 33 weeks.]
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2: Adequate [Is on tube feedings which meet nutritional needs for growth.]
3: Inadequate [Receives less than optimum amount of liquid diet for growth (formula/breast milk) and supplemented with intravenous fluids.]
4: Very poor [NPO on intravenous fluids.]
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2: Slightly limited [In a double walled isolette.]
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4: Completely bed-bound [In a radiant warmer with a clear plastic “saran” tent.]
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2: Slightly limited [Makes frequent though slight changes in body or extremity position independently.]
3: Very limited [Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.]
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2: Slightly limited [Lethargic.]
3: Very limited [Responds only to painful stimuli (flinches, grasps, moans, increased blood pressure or heart rate).]
4: Completely limited [Unresponsive (does not flinch, grasp, moan, increase blood pressure, or heart rate) to painful stimuli due to diminished level of consciousness or sedation.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Total score, description=The sum of all sub-scores., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=min: >=2; max: <=24

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1: At risk - Total score 13 or over [The neonate is not at risk of developing a pressure ulcer.]
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