Braden Risk Assessment Skills Essay

298 WordsNov 9, 20132 Pages
Braden Risk Assessment Scale Jhon lapid Nursing Skills Theory Ms. Jerry Sandoval October 25, 2013 Braden Risk Assessment Scale Mr. John Smith admitted from a long term care facility on October 25 2000. He is 100 years old and marital status is widowed. His subsequent diagnoses are: Alzheimer’s disease, cataracts, fracture, both right hips and undergone surgery at the Nova Scotia Health care center. He is unable to move and contracted. He doesn’t communicate verbally and his vision is highly impaired. He wears incontinent product (frequently bowel incontinent 3-4 times a week). His weight on October 25 2000 was 72kg. and his height was 157 cm. during admission. He is 20 kg. above the ideal weight range (48-59) for her age-height to weight ratio. He is on full diet (pureed) and thickened fluids. His nutritional risk is very high. Mr. Smith is totally dependent on activities of daily living like dressing, toileting, personal hygiene, oral care, eating, bathing and shampooing, transferring (mechanical lift) and sits on Geri chair or lounge chair during meals (Rillera, 2013). Mr. John Smith total Braden score = 9 – very high risk for decubitus ulcer or pressure sore. The following goals are presented to prevent pressure sore for this client are: 1. Promote skin care such as; cleanse skin at time of soiling, provide topical barriers for protection, skin assessment at least daily especially in pressure points, repositioning him every 2 hrs. and consider pressure redistribution when positioning in Geri chair or bed. 2. Place him on pressure redistributing mattress and chair cushion surfaces if possible. 2. Minimize environmental factors leading to dry skin (e.g. low humidity, cold air), use moisturizer for dry skin, 3. Maintain adequate nutrition and hydration Rillera, A. (2013, october 23). Registered

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