ARCHETYPE Modified Braden Q scale (openEHR-EHR-OBSERVATION.braden_scale_q.v0)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.braden_scale_q.v0
ConceptModified Braden Q scale
DescriptionThe Modified Braden Q scale is a tool used to assess the risk of pressure ulcer development in children aged between 21 days and 5 years.
UseUse to assess risk of pressure ulcer development in children aged between 21 days and 5 years. 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 the Braden Q scale for this purpose - OBSERVATION.braden_scale-q. The Braden Scale should not be used for children aged less than 21 days. Use the Neonatal Skin Risk Assessment Scale (NSRAS) for this purpose - OBSERVATION.nsras.
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: freshEHR Clinical Informatics, UK
Email: ian@freshehr.com
Date originally authored: 2011-08-01
Other Details LanguageAuthor name: Ian McNicoll
Organisation: freshEHR Clinical Informatics, UK
Email: ian@freshehr.com
Date originally authored: 2011-08-01
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=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=2DD276BFA2A93F684E3CEBEEB1816B90, build_uid=50c4784a-2779-4afa-b53f-9ec7f56e2ef8, 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=0.0.1-alpha}
Keywordspressure, sore, ulcer, Braden, adult, score, assessment
Lifecyclein_development
UIDe4a8da61-f40a-4bb1-ad64-ce8f2330c847
Language useden
Citeable Identifier1013.1.4190
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=[SNOMED-CT::413139004 | Braden assessment scale (assessment scale)], archetypeConceptDescription=The Modified Braden Q scale is a tool used to assess the risk of pressure ulcer development in children aged between 21 days and 5 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
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[LOINC::LA9603-7]

2: Very Limited [Responds to only painful stimuli. Cannot communicate discomfort except by moaning or restlessness; OR has sensory impairment that limits the ability to feel pain or discomfort over half of body.]
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3: Slightly Limited [Responds to verbal commands, but cannot always communicate discomfort or need to be turned; OR, has sensory impairment that limits the ability to feel pain or discomfort in one or two extremities.]
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4: No Impairment [Responds to verbal commands. Has no sensory deficit that would limit ability to feel or communicate pain or discomfort.]
[LOINC::LA9606-0]

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[LOINC::LA9607-8]

2: Very moist [Skin is often, but not always, moist. Linen must be changed at least every 8 hours.]
[LOINC::LA9608-6]

3: Occasionally moist [Skin is occasionally moist, requiring linen change every 12 hours.]
[LOINC::LA9609-4]

4: Rarely moist [Skin is usually dry, routine diaper changes; linen only requires changing every 24 hours.]
[LOINC::LA9610-2]

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2: Chairfast [Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.]
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.]
4: All patients too young to ambulate OR walks frequently [Walks outside the room at least twice a day.]
, 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 completely turn self independently.]
3: Slightly limited [Makes frequent though slight changes in body or extremity position independently.]
4: No limitations [Makes major and frequent changes in position without assistance.]
[LOINC::LA120-8]

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[LOINC::LA9615-1]

2: Inadequate [Is on a liquid diet or tube feedings/TPN, which provide inadequate calories and minerals for age OR albumin<3mg/dl OR rarely eats a complete meal and generally eats only half of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement.]
[LOINC::LA9616-9]

3: Adequate [Is on tube feedings or TPN, which provides adequate calories and minerals for age OR eats over half of most meals. Eats a total of 4 servings of protein each day. Occasionally eats between meals. Does not require supplementation.]
[LOINC::LA8913-1]

4: Excellent [Is on a normal diet providing adequate calories for age. For example, 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]

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[LOINC::LA9617-7]

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

3: Potential problem [Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraint or other devices. Maintains relative good position in chair or bed most of the time but occasionally slides down.]
[LOINC::LA9619-3]

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2: Compromised [Normotensive oxygen saturation may be <95%; haemoglobin may be <10mg/dl; capillary refill may be> 2 seconds; serum pH is < 7.40.]
3: Adequate [Normotensive oxygen saturation may be <95%; haemoglobin may be <10mg/dl; capillary refill may be 2 seconds; serum pH is normal.]
4: Excellent [Normotensive, oxygen saturation >95%; normal haemoglobin; capillary refill <2 seconds.]
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