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Braden-Skala de en PDF
Braden-Skala de en PDF
info
• Complaints can hardly be expressed (eg by • However, complaints can not always be
moaning or restlessness) or expressed (eg that the position should be
changed) or
• Disorder of pain sensation by paralysis • no fault of pain sensation
affecting the largest part of the body (for
example, high cross-section) • Disturbance of the pain sensation due to • disorder of pain sensation due to paralysis,
of which one or two extremities are affected
paralysis, half of the body is affected
mobility completely immobile Mobility severely limited Low mobility restricted mobile
nutrition very poor diet moderate diet adequate nutrition Good nutrition
eating habits
• never eats on small portions, but • rarely eats a normal portion of food, but • eats more than half of the normal • always eats the offered meals
eating in general, about half of the food food portions
only 2/3
offered
• eats only two or less servings of protein • takes four protein servings to be • takes 4 or more servings of
protein to be
(dairy products, fish, meat) • occasionally refused a meal, but will
supplement food to him or
• eat about 3 servings of protein • sometimes eats between meals
• drinking too little • regularly supplement food for themselves or
• assumes no supplementary food to him or • can take the most nutrients across probe or • does not need supplementary food
infusions
• not receive enough nutrients through tube
• must orally do not take food to him or feedings or infusions
Friction and shear forces problem potential problem no problem at the time
• takes a lot to massive support postural • something moves alone or need some • moving in bed and chair alone
help
• has enough strength to rise
• Lifting is not possible without loops over the • when pulling grinds the skin only slightly • may hold a position for a long time without
sliding down
sheets above the sheets (can, recover)
• slips kept falling in bed or in roll / chair, has to
be pulled up again • may be in a position hold for a long time
(chair, wheelchair)
• has spastic contractures or • is very restless • rarely slides down
(scrubs on the sheets)