braden scale翻译供参习.docVIP

Braden Risk Assessment Scale Braden风险评估表 NOTE: Bed and chairbound individuals or those with impaired ability to reposition should be assessed upon admission for their risk of developing pressure ulcers. Patients with established pressure ulcers should be reassessed periodically. 注意：应对卧床及不能走动（须借助轮椅）或者其他移动有障碍的患者进行压疮风险的评估。已有压疮的患者也应该周期性地接受评估。 Sensory Perception （感知能力） Ability to respond meaningfully to pressure-related discomfort 对压力引起的不适的反应能力 1. Completely Limited 完全受限 Unresponsive (does not moan, flinch or grasp) to painful stimuli, due to diminished level of consciousness or sedation. OR limited ability to feel pain over most of body surface. 由于意识的减退或者由于镇静剂的作用，患者对疼痛刺激无反应（不呻吟、不退缩或不握紧双拳）。或者指患者不能完全感受到大部分身体表面的疼痛。 2. Very Limited 非常受限 Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness. OR has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body. 患者只对有痛感的刺激有反应。除了呻吟或者烦躁不安外，患者无法表达不适。或者指患者存在感知障碍，从而限制了其对一半身体表面上疼痛或不适的感觉。 3. Slightly Limited 轻度受限 Responds to verbal commands, but cannot always communicate discomfort or need to be turned. OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. 患者对声音指令有反应，但是不能一直或者在翻身时才能表达不适。或者指患者存在感知障碍，从而限制了其对四肢中的一个或两个引起的疼痛或不适的感觉。 4. No Impairment 感知无障碍 Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. 患者对声音指令有反应。患者无感知缺陷，这些缺陷会限制患者感受或表达疼痛或不适的能力。 Moisture （潮湿度） Degree to which skin is exposed to moisture 皮肤暴露于潮湿环境的程度 1. Constantly Moist 始终潮湿 Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. 由于汗液、尿液等原因，患者皮肤一直潮湿。患者移动或翻身时都能发现皮肤的潮湿。 2. Very Moist 非常潮湿 Skin is often, but not always, moist. Linen must be changed at least once a shift. 皮肤经常但不是一直潮湿。每轮班必须更换床单、枕套。 3. Occasionally Moist 偶尔潮湿 Skin is occasionally moist, requiring an extra linen change approximately once a day. 患者皮肤有时潮