Home

Braden Scale PDF

Procedure/Documentation: Braden Risk & Skin Assessment

The Braden Scale has established validity and reliability and is a widely used risk used in all care settings and for adult populations. Factors not included in the Braden Scale such as advanced age, hypotension, hemodynamic instability, fever, prolonged ICU stay, severity of illness, comorbid. Braden Scale = 9 or < Preventative Interventions (Very High Risk) Use same protocol as for high risk patients Add a pressure redistribution surface for patients with severe pain or with additional risk factors. Best Use of Braden Scale. Dependent on nurses focus and attention on which Braden sub-categories are driving the overall risk level

Review areas of risk identified by the Braden Scale for a specific patient and other risk factors included as part of a structured comprehensive risk assessment. 2. Select interventions to address each area of risk that are consistent with patient preference and care goals. 3. Communicate a tailored pressure ulcer preventio SCALA DI VALUTAZIONE DEL RISCHIO SCALA DI BRADEN INDICATORI VARIABILI Percezione sensoriale: capacità di rispondere in maniera consapevole ai disturbi connessi all'aumento della pressione 1. Completamente limitata: Assenza di risposta (non geme , non si contrae o afferra) agli stimoli dolorosi dovuta alla riduzione dello stato d BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK Patient's Name Evaluator's Name Date of Assessment SENSORY PERCEPTION ability to respond meaningfully to pressure-related discomfort 1. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level.

The Braden Scale, developed in 1987, consists of six sub-scales: 1. Sensory perception 2. Moisture 3. Activity 4. Mobility 5. Nutrition 6. Friction and shear The individual receives a score between 1-3 or 4 points for each sub-scale item. The sub-scales are then summed for a total score, which ranges from 6-23.. Get And Sign Braden Scale Pdf Form . Or sedation. OR limited ability to feel pain over most of body 2. Very Limited 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 2 of body 2. Chairfast a. Provide above interventions as needed b. Obtain wheelchair cushion. c. Instruct/assist to shift weight in W/C q 15 minutes. Consider limiting W/C to 1-2 hour intervals BRADEN 1 Patient en situation d'alitement de quelques jours, se mobilisant seul et sans problème. Patient alité de 10 à 15 heures, qui se mobilise seul avec difficultés sans trouble neurologique important, sans artériopathie, état général bon à moyen. Patient levé dans la journée, alité plus de 15 heures www.slidetube.it INDICE DI BRADEN PER LA VALUTAZIONE DELLE LESIONI DA PRESSIONE 4 3 2 1 PERCESIONE SENSORIALE Abilità nel rispondere in modo corretto alla sensazione di disagio correlata alla pressione. Non Limitata. Risponde agli ordini verbali. Non ha deficit sensoriale che limita la.

Braden Scale Powerpoint PDF Diseases And Disorders

Braden Scale Pdf - Fill Out and Sign Printable PDF

  1. Braden Q Scale The Braden Q Scale for Predicting Pediatric Pressure Ulcer Risk (Braden Q Scale) is a widely used, valid, and reliable pediatric-specific pressure ulcer risk assessment tool. Since its original publication, requests for clarification on how best to use the tool across the wide spectrum of pediatric patient
  2. Braden-Skala zur Bewertung der Dekubitusrisiken* Risikograde: Allgemeines Risiko 18-15 Punkte Mittleres Risiko 14-13 Punkte Hohes Risiko 12-10 Punkte Sehr hohes Risiko < 9 Punkte 1 Punkt 2 Punkte 3 Punkte 4 Punkte Sensorisches Empfindungsvermögen Fähigkeit, adäquat auf druckbedingte Beschwerden zu reagieren fehl
  3. ing the risk of decubitus of . pedia. tric patients at PICU RSUP dr. Sardjito hospital. This is a diagnostic study that compare Braden scale and Glamorgan scale. Non probability sampling method where used to get 61 subjects. This research was conducted Desember 2013 - Januari 2014

Video: Scala di Braden: valutazione rischio di compromissione

Appendix O - NIC

Clicca qui per il Modulo in pdf da scaricare stampare e compilare o salva l'immagine qui in basso! Scala di Braden modulo da scaricare, stampare e compilare. Autore: Dario Tobruk (Profilo Linkedin) Fonti: Bergstrom, N et al. The Braden Scale for Predicting Pressure Sore Risk. Nursing research vol. 36,4 (1987): 205-10. Pressure ulcers Contents National Clinical Guideline Centre 2014. 5 O.7.3 : Braden scale cut-off score 19 - follow-up < 1 week - genera

braden scale Use the form only for the approved purpose. Any use of the form in publications (other than internal policy manuals and training material) or for profit-making ventures requires. Braden Scale Patient's name: Evaluator's name: Date of assessment: Sensory perception Ability to respond meaningfully to pressure-related discomfort 1.. Braden is less subjective - proven to provide high inter-rater reliability and consistency of patient risk assessment Recommended by NICE - Braden is the most validated and reliable risk assessment tool . A BIT ABOUT THE B RADEN SCALE Developed 1984 by Braden and Bergstrom.

Braden Scale Form by Jennifer Cook - Issu

Source : 1988 Barbara Braden et Nancy Bergstrom. La version originale a été reproduite avec la permission des auteures. Braden BI, Bergstrom N. Clinical Utility of the Braden Scale for Perdicting Pressure Sore Risk. Decub itus. 1989;2:44-51 Multisite web-based training in using the Braden Scale to predict pressure sore risk. Advances in Skin and Wound Care, 21(3), 124-133. Magnan, M., & Maklebust, J. (2008b). The effect of web-based Braden Scale training on the reliability and precision of Braden Scale pressure ulcer risk assessments. Journal of Wound The Braden Scale is one of the most commonly used tools to assess pressure ulcer risk in hospitalized and nursing home patients.11. The Braden Scale was developed by Bergstrom et al, in 1987, as a means to optimize prevention strategies and reduce the incidence of pressure ulcer. The Braden scale

Braden Scale-Understanding and Implementing Risk

BRADEN-SKALA 1 Punkt 2 Punkte 3 Punkte Datum Geburtsdatum 4 Punkte Punktezahl Sensorisches Wahrnehmungsvermögen Fähigkeit, lagebedingte wie künstliche Reize wahrzu-nehmen und adäquat zu reagieren. Feuchtigkeit Ausmaß, in dem die Haut Feuchtigkeit ausgesetzt ist. Aktivität Grad der körperlichen Aktivität. Mobilitä ブレーデンスケール:Braden Scale エーデル土山 褥瘡対策委員会 Edel tutiyama bed sore a measure committe 褥瘡発生のリスク・ファクターをアセスメントする1つの方法として褥瘡形成危険度チェック・リスト(Braden Scale)があります。これは新規入 Braden - bedömning av risken för trycksår . Man bör särskilt uppmärksamma patienter med nedsatt allmäntillstånd och nedsatt känsel liksom patienter som är sängbundna, rullstolsburna, har otillräckligt näringsintag eller har begränsad rörlighet och behöver hjälp för att ändra läge. Vad ska bedömas? • Rörlighe Braden-Skala zur Bewertung der Dekubitusrisiken* Risikograde: Allgemeines Risiko 18-15 Punkte Mittleres Risiko 14-13 Punkte Hohes Risiko 12-10 Punkte Sehr hohes Risiko < 9 Punkte 1 Punkt 2 Punkte 3 Punkte 4 Punkte Sensorisches Empfindungsvermögen Fähigkeit, adäquat auf druckbedingte Beschwerden zu reagieren fehl

Braden Scale | Eating | Pain

The Braden Scale for Pressure Ulceration Risk •NPUAP now calls pressure ulcers pressure injuries •In the US, considered the principle risk assessment tool, replacing the Norton and Gosnell scales •Used in hospitals, rehabilitation centers, skilled nursing facilities, LTACs and home health/hospic Braden Scale Assessment Overview Assessment Area ICF Domain: Body Function Subcategory: Functions of the Skin Subscales (domains): 1) Sensory Perception, 2) Moisture, 3) Activity, 4) Mobility, 5) Nutrition, 6) Friction and Shear Summary The Braden Scale is a clinician-administered assessment tool fo The Braden Scale is a scale made up of six subscales, which measure elements of risk that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure. These are: sensory perception, moisture, activity, mobility, friction, and shear. Each item is scored between 1 and 4,with each score accompanied by a. A bit about the Braden scale Developed 1984 by Braden and Bergstrom. Six elements that contribute to either higher intensity and duration of pressure or lower tissue tolerance to pressure therefore increasing the risk of pressure ulcer development. Sensory perception - Mobility (ability to change own position). Braden Scale - Assesses each client according to 6 subscales: sensory perception, skin exposure to moisture, the client's level of activity, the client's ability to change positions, nutritional intake and the presence of friction and shearing force. Total Braden Scale scores range from 6 to 23 with lower scores indicating higher risk

The Braden Scale for Predicting Pressure Sore Risk was developed to foster early identification of patients at risk for forming pressure sores. The scale is composed of six subscales that reflect sensory perception, skin moisture, activity, mobility, friction and shear, and nutritional status. Content and construct validity were established by expert opinion and empirical testing Unformatted text preview: ACTIVE LEARNING TEMPLATE: Diagnostic Procedure Sarah Anthony STUDENT NAME_____ Braden Scale PROCEDURE NAME_____ REVIEW MODULE CHAPTER_____ Description of Procedure Evidenced-based tool predicts the risk for developing a hospital or facility acquired pressure ulcer/injury Indications bedridden hx of pressure ulcers obese client in nursing home/assisted living facility. Admission Braden Scale and COVID- 19 Mortality several factors assoc iated with fra ilty, such as function, nu- trition, and cognit ion (Cohen et al. , 20 1 2; Cooper, 2 01 3; Ji While generic risk assessment tools such as Braden scale, Norton scale, Waterlow tool, and Ramstadius tool are available for predicting the risk of pressure ulcer formation, they are associated.

BRADEN SKALA PDF

Braden scale.pdf - Course Her

  1. Microsoft Word - Braden Assessment Case Study.docx Author: msutclif Created Date: 10/12/2011 9:43:58 AM.
  2. these scales, only the Braden Q Scale, the Glamorgan Scale, and the Neonatal Skin Risk Assessment Scale (NSRAS) have been tested for sensitivity and specificity.8,9,18,30,31 The Braden Q was developed for pressure ulcer risk identification in children aged 21 days to 8 years.8,9 The Braden Q contains the original 6 subscales of the Braden scale fo
  3. g risk items yields a total overall risk, ranging from 6-23. Scores 15 to 18 indicate at risk, 13 to 14 indicate moderate risk, 10 to 12 indicate high risk, ≤ 9 indicate very high risk. However, do not only rely on the total score
  4. Rose Little Hamm, in Physical Rehabilitation, 2007. The Norton Scale and the Braden Scale. The Norton Scale and the Braden Scale (the Braden Scale for Predicting Pressure Sore Risk) are the PU risk assessment tools recommended in the AHRQ Guidelines because they have been extensively evaluated. 1,20 When using the Norton or Braden Scales, patients should be assessed at the time of admission.

(Braden scale has been well validated in many studies to predict risk of pressure injury) Lyder, 2008 -AHRQ publication Lyder, 2008 -AHRQ publication Pancarbo-Hidalgo, 2006 At the study site - Pressure injury is assessed routinely on admission using the Braden scale Braden Scale Chart New T Score Chart Chart Designs Template - App Annie tracks all the different Feature placements for any app, day, country, category and device. Language Select Language Indonesian English

The Braden Scale for Predicting Pressure Sore Ris

Braden Scale: Braden評估表 4分 3分 2分 1分 感知能力 無損害 輕微受限 大部分受限 完全受限 潮濕程度 乾 燥 偶爾潮濕 常常潮濕 持續潮濕 活動力 經常行走 偶爾行走 局限於輪椅活 動 臥床不起 移動力 不受限 輕度受限 嚴重受限 完全不 The Braden Scale was developed by Barbara Braden and Nancy Bergstrom in 1988 and has since been used widely in the general adult patient population. The scale consists of six subscales and the total scores range from 6-23. A lower Braden score indicates higher levels of risk for pressure ulcer development แบบประเมินของบราเดน (The Braden Scale for Predicting Pressure Sore Risk) ฝ ายการพยาบาล โรงพยาบาลศิริราช การประเมิน คะแนน 19 - 23 ไม มีความเส ี่ยง (No risk • the Braden Scale (BS), first developed in 1984 by Braden and Bergstrom, is a tool de-signed to assess the patient's level of risk in developing pressure ulcers Authors: V Maida, MD, BSc, CCFP, ABHPM, Division of Palliative Medicine, William Osler Health Centre, University of Toronto, Toronto, Canada; F Lau, PhD, School of Healt The Braden Scale is a risk stratifying tool developed originally in 1987 by Braden and Bergstrom to be used in evaluating risk of pressure ulcers/injuries. There are 6 categories or subscales evaluated and a total score is obtained, where the lower the score, the greater the risk for developing an acquired ulcer/injury

Braden Q Scale | Nurse pics, Nursing online, Nursing notesScala di Braden - valutazione del rischio di

scala di braden La Scala di Braden è uno strumento utile per la valutazione del rischio di compromissione dell'integrità cutanea di un paziente. L'insorgenza di lesioni da pressione (dette anche lesioni da decubito) è una possibilità reale in pazienti allettati per lunghi periodi o con particolari abitudini di vita scala di norton, braden, Indice di Barthel, Scala di Hendrich, Mini Mental State, IADL, Geriatric Depression Scale - GDS, Maslow, Tinetti, Scala CHEOPS per Bambini, Scala di CONLEY, Waterlow prevention tretmen 1.1.3 Consider using a validated scale to support clinical judgement (for example, the Braden scale, the Waterlow score or the Norton risk-assessment scale) when assessing pressure ulcer risk. 1.1.4 Reassess pressure ulcer risk if there is a change in clinical status (for example, after surgery, on worsening of an underlying condition or with a. The focus of this story: the Braden Scale for Predicting Pressure Sore Risk. Developed by Barbara Braden and Nancy Bergstrom in 1984, 1 and now used in more than two dozen countries, the Braden Scale is an evidence-based tool that provides strong risk assessment value when used correctly. It's a quantitative and universal standard that's. The Braden Scale is a risk assessment tool for pressure injuries that takes into account 6 factors. Do you want to know the degree of risk of pressure injuries (PIs)? Fill in the Braden Scale and find out the risk index. Sensory Perception . Ability to respond meaningfully to pressure related discomfor

Braden-Skala zur Bewertung des Dekubitusrisikos Übersetzung: Heidi Heinhold; autorisiert durch Barbara Braden 1 Punkt 2 Punkte 3 Punkte 4 Punkte sensorisches Wahrnehmungs- vermögen Fähigkeit, lagebedingte wie künstliche Reize, z. B. Druck, wahrzunehmen und adäquat zu reagieren vollständig ausgefallen Keine Reaktion au TT SAFE Med ApS, Blytaekkervej 10, 8800 Viborg, Denmark, Tel. +45 8662 1400, www.safemed.dk 03/2018 NAVN: SCORESKEMA med brug af BRADEN Person nr. مقياس برادن للتنبؤ بمخاطر قرحة الفراش، هو أداة طُورت في عام 1987م على يد باربارا برادن ونانسي بيرجستورم. ويتمثل الهدف من هذا المقياس في مساعدة المتخصصين، وخاصة الممرضات، في تقييم مخاطر المريض فيما يتعلق بتطور قرحة الفراش Risk scales will always be used where they have shown efficacy in clinical practice as a complementary tool. For example, Norton or Braden scales have been developed in acute care hospital settings, as well as in nursing homes, Waterlow scale and other scales in the field of paraplegiology, and are mainly used in these centers

Breaking Down the Brade

PURPOSE No risk assessment scale exists in the United States specifically designed for use among patients with critical illness. The aim of this project was to modify the Norton Scale for Pressure Sore Risk to improve its predictive power when used in the critical care setting. PARTICIPANTS AND SETTING The setting for this quality improvement project was a 1157-bed academic medical center in. Braden Scale and the MDS together. A chart review of 8 US homes in which MDS and Braden Scale data were available compared the Braden Scale and the MDS Resident Assessment Protocol (RAP), concluding that there was good potential for MDS information to take the place of the Braden Scale [16]. An examina-tion of MDS items and Braden Scale domains.

Braden Risk Assessment too

[PDF] The Braden Scale for Predicting Pressure Sore Risk

Braden Scale: The Braden Scale for predicting PU risk, is a instrument that was developed in 1987 by Barbara Braden and Nancy Bergstrom. The purpose of the scale is to help health professionals, especially nurses, assess a patient's risk of developing a PU (16,23,28). The Braden Scale is composed of six subscales that reflec scale di Norton e di Braden SCALA DI NORTON modificata secondo Nancy A. Scotts INDICATORI Condizioni generali: livelli di assistenza richiesti per le ADL( capacità di fare il bagno, di vestirsi, di usare i servizi igienici, mobilità, continenza, alimentazione) Appendix C: Braden Scale for Predicting Pressure Sore Risk Risk Assessment & Prevention of Pressure Ulcers 60 SENSORY PERCEPTION ability to respond meaningfully to pressure-related discomfort MOISTURE degree to which skin is exposed to moisture ACTIVITY degree of physical activity MOBILITY ability to change and control body position NUTRITION.

Braden Scale Diagnostic Procedure

  1. The Braden Scale for Predicting Pressure Sore Risk should be conducted for the purpose of planning preventive interventions and that the prevention plan should be based on assessment of individual Braden subscale scores. Appendix J Individual Braden Subscale Intervention Checklist.pdf
  2. Fill each fillable area. Ensure the data you fill in Braden Scale Form Pdf is up-to-date and accurate. Include the date to the template with the Date option. Click the Sign button and create a signature. You will find 3 available options; typing, drawing, or uploading one. Check once more each field has been filled in properly
  3. ing six criteria. The total score can range from six to 23, with the lower score indicating a higher risk. Criteria for Assessment
  4. scale to classify the type of stool passed. This helps assess how long the stool has spent in the bowel. Type 1 has spent the longest time in the bowel and type 7 the least time. A normal stool should be a type 3 or 4, and depending on the normal bowel habits of the individual, should be passed once every one to three days
  5. The Braden Scale is a consolidated instrument in pressure injury prevention. Methods: It is a descriptive-exploratory research with a qualitative approach, which has been performed in a hospital localized in North of Rio Grande do Sul State. Data were collected through semi
  6. The Braden Scale is helpful in this regard. Patients are scored on this scale with points ranging from highest risk, 6, to lowest risk, 23. Braden scoring can be broken into five strata: very high risk (6-9), high risk (9-11), moderate risk (12-14), at ris
  7. the Braden Scale within 72 hours after admission of the patient and in the records in the electronic handbook. The score relation versus risk is inversely proportional, so the lower the value of the score, the greater the risk of the individual to develop PI. The data collected wer

The Braden Scale for Predicting. Pressure Sore Risk. Discussion & Conclusion: In order to reduce the risk of pressure injury development, it is important to identify patients at risk for malnutrition and intervene early. The use of a validated nutrition screening tool, such as the MST, can help to identify these patients more effectively than. The Braden Scale f validated instrument f used to aid professional and clinical judgment f full patient profi le context f composed of six sub-scales that refl ect sensory perception, skin moisture, activity, mobility, friction and shear, and nutritional status f fi ve of the six sub-scales are rated from one (1) (leas

The Braden Scale for Predicting Ulcer Risk |authorSTREAM

(PDF) Admission Braden Scale Score as an Early Independent

(PDF) Norton, Waterlow and Braden scores: A review of the

  1. The Braden Scale activity categories are broken down by: Bedfast: confined to bed—think of residents with severe stroke, spinal cord injury, on bedrest due because of a wound or other issue. Chairfast: ability to walk severely limited or nonexistent. These persons cannot bear own weight and/or must be assisted into a chair or wheelchair.
  2. The Braden(ALB) scale was even more valid than the Braden scale (z=1.860, P=0.0628). In different age subgroups, the Braden(ALB) scale seems also more valid than the original Braden scale, but no statistically significant differences were found (P>0.05)
  3. Braden scale requires obtaining permission at www.bradenscale.com or (402) 551-8636. Breaking Down the Braden Risk Factor: Immobility •Anything that contributes to limiting mobility should also be listed as a risk factor: Diagnosis: CVA, MS, Paraplegia, Quadriplegia, en

Braden Scale - an overview ScienceDirect Topic

  1. The primary aim of this tool is to assist you to assess risk of a patient/client developing a pressure ulcer. The Waterlow consists of seven items: build/weight, height, visual assessment of the skin, sex/age, continence, mobility, and appetite, and special risk factors, divided into tissue malnutrition, neurological deficit, major surgery/trauma, and medication
  2. ing all the data
  3. This INTERVENTION PROTOCOLS FOR BRADEN SCALE SUBSCALES PDF file is documented within our data source as JNMFNRNOXY, having file size for around 427.22 and then submitted in 28 Jan, 2014
  4. Ecco la Scala di va l utazione Braden. Uno strumento utile per valutare integrità cutanea e riuscire a prevenire l'insorgenza di lesioni. La Scala Braden è una delle scale infermieristiche più utilizzate per la valutazione del rischio all'integrità cutanea e insorgenza di UdP.. La sua valutazione è necessaria alla presa in carico ed altrettanto necessaria è la sua rivalutazione.
  5. ated rapidly! People from around the world began asking for permission.
  6. The Braden Scale is a summated rating scale made up of six subscales scored from 1-4 (1 for low level of functioning and 4 for the highest level or no impairment). Total scores range from 6-23 (one subscale is scored with values of 1-3, only). The subscales measure functional capabilities of the patient that contribute to either higher.
Predicting Pressure Ulcer Sore Risk

B. Skala Braden. 1. Pengertian Skala Braden. Skala Braden untuk memprediksi resiko dekubitus adalah alat yang dikembangkan pada tahun 1987 oleh Barbara Braden dan Nancy Bergstorm. Universitas Sumatera Utara Tujuan dari skala ini adalah untuk membantu para profesional kesehatan khususnya perawat, dalam menilai resiko terjadinya luka dekubitus Braden Scale, Wound Care 101, Wound Care. By Holly Hovan MSN, APRN, GERO-BC, CWOCN-AP. Wound care and healing require an evidenced-based, interprofessional approach, following standards of care, and treating the whole patient, not just the hole in the patient. Often, wound care clinicians are consulted for recommendations on the treatment of.

HD MED: Februari 2012

Predictive and Concurrent Validity of the Braden Scale in Long-Term Care: A Meta-Analysis. Published by Wound Repair And Regeneration : Official Publication Of The Wound Healing Society [and] The European Tissue Repair Society, 11 February 2015. prevention is an important long-term care (LTC) quality indicator Braden Scale Protocals by Level of Risk AT RISK (15-18)* FREQUENT TURNING MAXIMAL REMOBILIZATION PROTECT HEELS MANAGE MOISTURE, NUTRITION AND FRICTION AND SHEAR PRESSURE-REDUCTION SUPPORT SURFACE IF BED- OR CHAIR-BOUND * If other major risk factors are present (advanced age, fever, poor dietary intake of protein

The Braden scale for predicting pressure sore risk [34-37], more commonly called the Braden scale , is the most widely used tool in hospitals to identify patients at high risk for HAPUs. The Braden scale is highly effective in assessing HAPU risk among patients in medical, surgical, and critical care settings [ 40 ], and is more accurate than. Currently unavailable.. 4.1 out of 5 stars 4. 3b9d4819c4. o efeito isaias gregg braden pdf 72 metal gear solid 2.... Petroleum, Gregg Braden um cientista conhecido descoberta do Grande Cdigo Isaas nas cavernas do Mar do seu DNA para que o efeito continuasse a... Ayello EA, Braden B. How and why to do pressure ulcer risk assessment. Adv SkinWound Care. 2002 May-Jun;15(3):125-131. Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden Scale for Predicting Pressure Sore Risk. Nurs Res. 1987;36:205-210. Braden Scale for Preventing Pressure Sore Risk. Prevention Plus. 2001 www.healthywa.wa.gov.a Braden Scale Pressure Ulcer Table. . Probably Inadequate. The above Braden scale for predicting Pressure Sore risk chart provides the chart with different score according to the category. On adding the scores in the Braden scale Pressure Ulcer table, the overall score can fall between 6 to 23 and the lower score indicates the higher risk Braden Scale Results of the pressure ulcer survey at UHS reported that of the 387 nurses that participated in the survey, 35% reported receiving formal training on the Braden Scale. The units with no formal training program reported inter-rater reliability of: Sensory 0.220-0.947, Moisture 0.093-0.640