Question

An 80 year old female was admitted to your unit from the Emergency department after falling at home and lying on the floor for 2 days. Her admitting diagnosis is Stroke with left hemiparesis. Your assessment reveals a frail emaciated female with DTI (deep tissue injury) to her sacrum and heels. She is incontinent of urine and stool. There is peri-anal excoriation secondary to her incontinence. A foley catheter is placed upon admission. However, she remains incontinent of stool requiring her linen to be changed once a shift. She claims that she has not eaten in 2 days. Physical Therapy has seen her; she is too weak to make significant changes in bed but did get up to the chair with Therapy.

A 49 year old male is admitted to your unit following surgery for a torn rotator cuff that he sustained from playing hockey. He is moving freely while in bed and has already been up to the bathroom without assistance. The first thing that he says to you is that he is hungry and has not eaten since dinner last night. Your assessment reveals a well-nourished male, dry intact skin, with a sling on his left arm. His neuro-circulation check on his left upper extremity demonstrates a strong radial pulse, good capillary refill and the ability to move his fingers. He told you that he follows a high protein diet, eats three meals a day with an additional protein supplement between lunch and dinner. He also stated that he does not consume alcohol. 10. Based on the information above how would you score the Braden Scale sub-categories? Sensory Perception Moisture Activity Mobility Nutrition Friction and Shear Total Score

Answer 1

Braden Scale is the most preferred tool to evaluate the patient's risk for pressure ulcers. It comprises of six categories namely sensory perception, moisture, activity, mobility, nutrition, friction and smear. Each category can be scored up to 4 where 1 is completely limited, 2 is very limited, 3 is slightly limited, and 4 is No impairment.

Based on the information provided, the 80-year old female were scored as

Sensory perception - Sensory impairment over half of the body   - very limited - 2

Moisture - Linen has to changed in every shift - Very limited   - 2

Activity - get up to chair with assistance   - Chairfast - 2

Mobility - Unable to make significant changes independently - Very limited   - 2

Nutrition - Eat occasionally - Probably inadequate - 2

Friction and smear - Need maximum assistance in moving - Problem   - 1

Total Score = 11

Score 11 indicates high risk, so the protocol of preventive measures such as turning of position, healing of wounds, encourage the activity to maximum, moisturing of the pressure areas, Prevention of friction should be followed. Frequent changing of position is necessary to prevent a pressure ulcer.

Based on the information provided, the 49-year-old male is scored as

Sensory perception - impairment of left upper extremity - Slightly limited - 3

Moisture - Usually dry - Rarely moist - 4

Activity - Moves to the bathroom without assistance - walks occasionally - 3

Mobility - Frequent changes independently - No limitation - 4

Nutrition - well nourished, eats between the meals - Excellent - 4

Friction and smear - Moves independently in bed and chair - No apparent problem - 4

  Total Score = 22

This patient score is 22 which indicates that he is not at risk for the pressure sore.