Braden Scale_ Discussion
Mr Smith is bedridden a long term care facility due to stroke and is highly susceptible to pressure ulcers. It is important to assess his risk of developing a pressure ulcer. Braden scale is a six-item tool for evaluating the risk of developing pressure ulcer (Magnan, & Maklebust, 2009). Pressure ulcers or bedsore are localized damage to the skin and underlying tissue as a result of prolonged pressure and often in combination with the friction or shear. Bedsores commonly develop on the bony areas of the body like ankles, heels, tailbone, and hips. The scores range from a minimum of 6 to the highest score of 24 on this tool (Cho & Noh, 2010). A higher score is preferred than lower scores on the scale. Mr Smith has a total score of 9 on the Braden scale, indicating that the patient is at severe risk of developing a pressure ulcer. Accordingly, a score of less 12 suggests that a patient is at a high risk of developing pressure ulcers.
The highest scoring is on sensory perception. The patient scored 3/4 on this item because he displays a slightly limited ability in response to significant pressure-related discomfort. The second most scoring was on the nutrition item with scoring of 2/4, resulting in his inability to eat a complete meal. The patients scored the lowest at the remaining items: moisture, mobility, activity, and shear or friction. Regarding shear and mobility items, the patient needs moderate to maximum support in moving because he is completely immobile and bedridden due to stroke. Consistent with Caldini et al. (2017), Mr Smith is at severe risk of developing bedsores and relevant mitigation measures like physical needed to improve his muscles and movements.
References
Caldini, L. N., Silva, R. A., Melo, G. A. A., Pereira, F. G. F., Frota, N. M., & Caetano, J. Á. (2017). Nursing interventions and outcomes for pressure ulcer risk in critically ill patients.
Cho, I., & Noh, M. (2010). Braden Scale: Evaluation of clinical usefulness in an intensive care unit. Journal of advanced nursing, 66(2), 293-302.
Magnan, M. A., & Maklebust, J. (2009). Braden Scale risk assessments and pressure ulcer prevention planning: what’s the connection?. Journal of Wound Ostomy & Continence Nursing, 36(6), 622-634.