WEEK 6: INTEGUMENTARY CONCEPT: BRADEN SCALE
This week concept is about care for the integumentary system. Skin integrity assessment is an essential part of nursing care and should be conducted on admission and at least daily depending on the individual’s circumstances. High-risk patients require skin inspection at least once per shift in addition to admission to a unit and or in any change in patient’s clinical condition. A skin assessment captures the patient’s general physical condition, based on careful inspection and palpation of the skin and documentation of your findings. Nurses know pressure ulcers are one of the biggest challenges in caring for patients. Patient admitted in a health facility is assessed for their vulnerability or predictive risk and that preventive measures can be instituted. Critical care patients are at an especially high risk, because of increased use of medical devices such as catheters and feeding tubes, among others, being bedridden and conditions that restrict flow of blood to the skin such as vascular diseases and diabetes.
To fully assess and prevent the patient’s risk of developing pressure ulcer, the Braden Scale is utilized, an evidenced-based tool, developed by Nancy Braden and Barbara Bergstrom that predicts the risk for developing a hospital or facility acquired pressure ulcer/injury. This is comprised of six different subscales namely: Sensory and Perception, Moisture, Mobility, Activity, Nutrition and Friction and shear. The Braden Scale uses a scores from less than or equal to 9 to as high as 23. A score of 23 means there is no risk for developing a pressure ulcer while the lowest possible score of 6 points represents the severest risk for developing a pressure ulcer.
In this assignment you are given a scenario that you will assess and analyze. Using the Braden Scale you will score your respective patients as they are presented in the case scenario assigned to you.
Adult Scenario Key: Scenario No. 5
Lament Cruise is 67 y/o admitted for respiratory failure with a diagnosis of Covid-19.
He has history of asthma and Type I Diabetes. He is admitted in the Medical Intensive Care Unit and was placed on mechanical ventilator with on-going drip medications such as Fentanyl for pain, Propofol for sedation, Nimbex drip for paralytics and was just started on Norepinephrine drip for blood pressure support all via central line inserted on the right subclavian vein.
On the start of the shift he was NPO but has a new order of TPN to be stated for nutritional management but will not come till 1200 noon. You took the finger stick at 8:00 and was 400 g/gl.
You checked the patient pressure areas and have seen Stage 2 pressure ulcer on the sacral area. He has a foley catheter for strict monitoring of the intake and output. His current vital signs as follows: Temp. 102.3 , HR 122, BP=100/68, RR=33, Saturations=91%. His skin is hot to touch and continuous cooling blanket is applied . Weight is 78.8 kgs, Height 177.5 cms. He is critically guarded.
• Using the Braden Scale Assessment Tool, how would you score Lament Braden Pressure Ulcer Risk ?
• Develop a Nursing Care Plan on Integumentary nursing problem. Use the NCP format sent.
• Caveat: Nursing diagnosis should follow the (Problem-Etiology-S/Sx ) and has to have a Rationale. Example: Fever: Alteration in body temperature, more than normal related to infection process as evidenced by: (subjective and objective cues) Rationale: During infectious process, chemical mediators such as pyrogenes are released in the bloodstream. The body’s thermo-regulating center (hypothalamus) causes the reset to a higher temperature as a response-thus fever will ensue.
• Interventions should be based on the different subscale of Braden Scale Pressure Ulcer Tool.
