The Braden scale is an important assessment method for determining the risk of pressure ulcers. The specific methods of assessment are:
1. Perception ability: the ability to respond to discomfort caused by stress. ? 1 point is fully restricted, most of them are 2 points, 3 points are slightly restricted, and 4 points are no damage.
2. Humidity: the degree of skin contact with moisture. Continuous humidity is 1 point, humidity is 2 points, occasional humidity is 3 points, rare moisture is 4 points
3. Mobility: 1 point for bed, 2 points for chair, 3 points for occasional walking, 4 points for frequent walking point.
4. Liquidity: Absolutely no movement allowed by 1 point, extremely restricted by 2 points, slightly restricted by 3 points, and not restricted by 4 points.
5. Friction and shear force: A score of 1 indicates a problem, a score of 2 indicates a potential problem, and a score of 3 indicates no problem.
6. Nutritional intake: 1 point for extremely poor, probably less than 2 points, 3 points for adequate, and 4 points for richness. Scores below 11 are classified as high risk, hazard levels are 12 to 14, hazard levels are 15 to 17, and hazard levels are greater than or equal to 18. Extended information
The latest classification of the U.S. National Pressure Ulcer Advisory Panel in 2007
(1) Suspected deep tissue injury. The subcutaneous soft tissue is damaged by pressure or shear force, and the local skin is intact but can be damaged. A color change such as purple or maroon, or blisters that cause congestion. The soft tissue in these damaged areas may be painful, hard, sticky, moist, warm, or cold compared to surrounding tissue.
(2) The first stage of pressure ulcer congestion and rosy stage - "redness, swelling, heat, pain or numbness that lasts for 30 minutes". The skin at the bony prominence is intact with inability to press. Faded localized erythema. Darker skin may not appear noticeably pale, but may be a different color than surrounding tissue.
(3) The second stage of pressure ulcer inflammatory infiltration stage - "purple, induration, pain, blisters", part of the dermis is missing, manifesting as a shallow open ulcer with pink wounds The bed (wound), without slough, may also appear as an intact or ruptured serous blister.
(4) The third stage of pressure ulcer is shallow ulcer stage - epidermal damage and ulcer formation. Typical features: full-thickness skin tissue loss, subcutaneous fat exposed, but bones, tendons, and muscles not exposed, slough present, but the depth of tissue loss is unclear, and may include sneaking and tunnels.
Baidu Encyclopedia-Pressure Ulcer