Moisture
Constantly moist— The incontinence and inability to “feel” wet places her in a high-risk situation. repositioning herself, she is unable to bear her own weight, needing assistance. Bedfast—If she needs help
Moist
Occasionally moist
Rarely moist
Activity
Chair fast
Walks occasionally
Walks frequently
Mobility
Completely immobile
Very limited— She needs help turning and repositioning but is not completely helpless.
Slightly limited
No limitation
Nutrition
Very poor—Her recent weight loss and lack of appetite place her at a very poor nutritional situation. Problem— Assistance with movement for listing and sliding is needed.
Probably inadequate
Adequate
Excellent
Friction and sheer
Potential problem
No apparent problem
Total Score
4
4
0
0
Goals Students will begin the process of data collection in the assessment of risk for skin breakdown and pressure sore development. Online Application • Ask students to complete the template for this activity based on the scenario for Paula. Each student should upload it to the course learning management system. • Ask students to submit a scenario like the one for Paula and upload it the course discussion. Classmates would determine the Braden score based on the information given.
Interpretation: Wound Assessment
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