The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 25: Prevention of Skin Breakdown26 picasTable 25-4: Braden Risk Assessment Tool (continued)NutritionUsual food intakepattern1. Very poor:Never eats a complete meal.Rarely eats more than 1/3 ofany food offered. Eats 2servings or less of protein(meat or dairy products) perday. Takes fluids poorly. Doesnot take a liquid dietarysupplement OR is NPO and/ormaintained on clear liquids orIV’s for more than 5 days.2. Probably inadequate:Rarely eats a complete meal andgenerally eats only about ½ ofany food offered. Protein intakeincludes only 3 servings of meator dairy products per day. Occasionallywill take a dietarysupplement OR receives lessthan optimum amount of liquiddiet or tube feeding.3. Adequate:Eats over half of most meals.Eats a total of 4 servings ofprotein (meat, dairy products)each day. Occasionally willrefuse a meal, but will usuallytake a supplement if offeredOR is on a tube feeding or TPNregimen which probably meetsmost of nutritional needs.Friction andShear1. Problem:Requires moderate tomaximum assistance inmoving. Complete liftingwithout sliding against sheetsis impossible. Frequentlyslides down in bed or chair,requiring frequentrepositioning with maximumassistance. Spasticity,contractures or agitation leadto almost constant friction.2. Potential problem:Moves feebly or requiresminimum assistance. During amove skin probably slides tosome extent against sheets,chair, restraints, or otherdevices. Maintains relativelygood position in chair or bedmost of the time, butoccasionally slides down.3. No apparent problem:Moves in bed and in chairindependently and hassufficient muscle strength tolift up completely during move.Maintains good position in bedor chair at all times.Note: Patients with a total score of 16 or less are considered to be at risk of developing pressure ulcers.(15 or 16 = low risk, 13 or 14 = moderate risk, 12 or less = high risk)Source: As printed in the AHCPR Clinical Practice Guideline No.3. Pressure Ulcer in Adults: Prediction and Prevention. May 1992.XXV4. Excellent:Eats most of every meal. Neverrefuses a meal. Usually eats atotal of 4 or more servings ofmeat and dairy products.Occasionally eats betweenmeals. Does not requiresupplementation.TOTAL SCOREU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 509