ARCHETYPE Neonatal Braden scale (NSRAS) (openEHR-EHR-OBSERVATION.braden_scale_neonate.v1)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.braden_scale_neonate.v1
ConceptNeonatal Braden scale (NSRAS)
DescriptionNeonatal Skin Risk Assessment Scale (NSRAS), an instrument to assess neonates at risk for skin breakdown, based on the Braden Scale for Predicting Pressure Sore Risk in adults.
UseThe Neonatal Skin Risk Assessment Scale (NSRAS) should only be used to assess nenoates under 21 days of age.
MisuseDo not use for pressure sore risk assessment in children aged over 21 days. Use the Braden-Q scale for children between 21 days and 5 years of age - OPEN-EHR-EHR-OBSERVATION.braden_child.v1 Use the adult Braden Scale for children over 5 years of age and adults - OPEN-EHR-OBSERVATION.braden_scale.v1
PurposeTo record details of an assemment based on the Neonatal Skin Risk Assessment Scale (NSRAS). The NSRAS is designed to allow the assessment of neonates at risk of skin breakdown or pressure sore development, based on the Braden Scale for predicting Pressure Sore Risk in adults. 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, particuarly that a high score is accociated with high risk, the opposite from these other Braden scales where a low score equates to high risk.
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: Ocean Informatics, UK
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 2011-08-08
Other Details LanguageAuthor name: Dr Ian McNicoll
Organisation: Ocean Informatics, UK
Email: ian.mcnicoll@oceaninformatics.com
Date originally authored: 2011-08-08
OtherDetails Language Independent{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, Ocean Informatics, UK, ian.mcnicoll@oceaninformatics.com, MD5-CAM-1.0.1=81DFA726CC9BF96D198F7FEFB30B5895}
Keywordsbraden, neonate, score, skin, pressure, ulcer, sore
LifecycleAuthorDraft
Language useden
Citeable Identifier1013.1.1035
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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 dgree 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.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=4, text=Mobility, description=The neonate's ability ot 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=null, values=1: No limitation [Makes major and frequent changes in position without assistance (e.g., turn head).]
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[at0016], code=at0016, itemType=ELEMENT, level=4, text=Comment, description=An additional comment about the neonatal pressure risk assessment., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Total score, description=The total score, derived from the sum of all sub-scores for identifying if a neonate is at risk for pressure ulcers., 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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3: Poor [Gestational Age > 28 Weeks But < 33 weeks.]
4: Very poor [Gestational Age > 28 Weeks But < 33 weeks.]
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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.]
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2: Adequate [Is on tube feedings which meet nutritional needs for growth.]
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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.]
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0008], code=at0008, itemType=ELEMENT, level=4, text=Mobility, description=The neonate's ability ot 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=null, values=1: No limitation [Makes major and frequent changes in position without assistance (e.g., turn head).]
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.]
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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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