Question

In: Nursing

Mrs. X, a 25-year-old woman that is alert but confused to time; she has peripheral neuropathy...

Mrs. X, a 25-year-old woman that is alert but confused to time; she has peripheral neuropathy from being a type one diabetic in both of her feet. She has not required additional linen changes. She has been on bedrest due to her blood pressures. She can make position changes on her own, and she can lift herself up in the bed independently. Because of her diagnosis, she is currently NPO.

Sensory perception: __________

Moisture: ____________

Activity: _____________

Mobility: ____________

Nutrition: _____________

Friction/Shear: _______________

Total: ____________ -- Is this patient at risk for skin breakdown? How do you know?

Mr. O is a 40-year-old Iraqi veteran. He is nonverbal following a head injury. Communication with him is very difficult. Because of his inability to follow commands, Mr. O requires feeding through a feeding tube. He is receiving his tube feeding formula at the goal rate. Mr. O frequently sweats due to his injury, and requires a linen change every shift. Mr. O ambulates 100 feet in the hallway twice a day with therapy. He does not reposition independently, as he favors his R side over his L. Because of this, staff must assist with turns. He must also be pulled up in the bed a few times a shift.

Sensory perception: __________

Moisture: ____________

Activity: ____________

Mobility: ___________

Nutrition: _____________

Friction/Shear: _______________

Total: ____________ -- Is this patient at risk for skin breakdown? How do you know?

Expert Solution

Answer 1.

Based on the Braden scale we can predict the risk of skin breakdown
Braden scale was developed by Barbara Braden and Nancy Bergstrom in 1987
The scale is made up of 6 categories.
Each category is scored 1 to 4 except friction (1 -3 ). 1 = worse whereas 4 = Best
The total score is then calculated.
Higher the score lesser chances of skin breakdown. and vice versa
The lowest score possible - 6
The highest score possible - 23
A score of less than 18 or less associated with increased risk of skin breakdown

Risk stratification is based on the total score -

15 - 18 = at risk
13 - 14 = Moderate risk
10 - 12 = high risk
9 or less = very high risk

Answer 1: Moderate risk as per the Braden scale.

The Braden score for Mrs. X can be calculated as

Category	score	Justification
sensory perception	1	The patient is alert but confused The patient has developed peripheral neuropathy so her sensory perception must be impaired
Moisture	4	Because she doesn't need additional linen changes
Activity	1	The patient is bedridden
Mobility	4	The patient can change her position She can lift herself independently
Nutrition	1	patient is NPO
Friction/ shear	3	as the patient can move independently, it is unlikely that the patient slides on her bed or chair Sliding causes shear - the bone and skin move in the opposite direction and causes tissue damage

Total score - 14

The risk for skin breakdown as per Braden scale is a moderate risk

Answer 2 - The risk for skin break down is high

Categories	Score	Justification
Sensory perception	1	As he has suffered a head injury
Moisture	1	As the patient sweats and requires repeated linen change
Activity	3	He is able to move around.
Mobility	1	The Patient needs the help of the nurse.
Nutirtion	4	The patient is receiving nutrition on a regular basis
Friction/ shear	1	The patient requires the help of the moving around and he sweats a lot.

Total score - 11

The risk for skin break down is high

Nightingale answered 2 years ago

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