Braden Self Study Guide Answer Key for VUH To be used on conjunction with Braden in HED Self Study Guide for VUH

Key points: 1.Moisture Risk Factor documented; Braden score 19, standard risk 2.Skin Integrity Risk documented and Moisture Control Care initiated Adult Scenario Key: Scenario #1, part 1 John Doe is a 24 year old male admitted 2 days ago for Fever of Unknown Origin (FUO). He is otherwise healthy except for the fever accompanied by profuse diaphoresis. He is ambulatory and repositions himself in bed regularly. He has lost 10 lbs. since the onset of the illness but has a good appetite and routinely eats most of his regular diet. Pressure points are free of any redness, swelling or irritation. Based on this information, how would you score his Braden Pressure Ulcer risk level?

Key points: 1.Nutrition Risk Factor documented (and Nutrition Risk factor displays in Nutrition by Nursing) ; Braden score 17, at risk 2.Skin Integrity Impairment Problem documented and Moisture Control Care initiated Adult Scenario Key: Scenario 1, Part 2: John has developed very severe diarrhea with 8-12 episodes of liquid stool/day. His perianal area is excoriated; he was started on a Bowel Management System to reduce skin irritation. The fever with extreme diaphoresis episodes continue. John’s activity level has decreased but does reposition him-self frequently and other than the perianal skin issues other pressure points remains free of redness and irritation. Since the onset of diarrhea John’s appetite has been very poor. How would you score John’s Braden Pressure Ulcer risk level? Would you document the compromised perianal skin and if so how?

Adult Scenario #2, Part 1: Mary Doe is an 84 year old female admitted for elective CABG. She is embarrassed that she sometimes has difficulty getting to the bathroom when she has urgency to void and wears adult diapers as a result. She has some reddened areas in her perineal area that she says have gotten worse since her Lasix dose was increased. Mrs. Doe occasionally ambulates slowly in her room without assistive devices. Movement in bed appears to be challenging and she has difficulty lifting her own weight to turn. She has HOB elevated 45 degrees regularly in order to breathe more easily. She tends to stay on her back because of this. Skin is warm and dry. She has slight bilateral irritation on elbows, 2+ pitting edema & some lack of sensation in both lower extremities. Her dietary intake varies but she often eats less than half of the meal and seldom has more than 3 servings of protein or dairy products in a day. How would you score her Braden Pressure Ulcer Risk level? Key Points : 1.Moisture, Mobility, Nutrition, and Friction/Shear Problems with Braden score 13, at risk. 2.Mobility, Activity, and Nutrition risks also display under their Care Categories. 3.Monitoring and Care documented with annotations used as needed to individualize for patient.

Adult Scenario #2, Part 2: Mrs. Doe tolerated the CABG well initially but spiked a fever < 48 hours post op and was started on IV antibiotics. Today the incision opened up spontaneously. Other skin assessment largely unchanged since one week ago with the exception that she no longer has edema in lower extremities. How would you score Braden Pressure Ulcer risk level? How would you document her incision/wound? Key Points : 1.Same Risk Factors and Risk score. 2.Impaired skin integrity Problem documented. 3.Skin condition issue resolved so WNL noted. Other monitoring and intervention care documented.

Adult Scenario Key: Scenario #3 Jane Doe is a 58 year old female admitted for chemotherapy for carcinoma of the large bowel. She has a colostomy that was placed 3 months ago. Ms. Doe said she doesn’t usually eat much during chemo but has good appetite and has maintained weight since beginning therapy. She does not feel like doing much activity during chemo infusion but walked in halls prior to therapy this morning. No sensory deficits. Repositions self in bed frequently without assistance or apparent friction/shear. Skin is warm and dry but she does report a 3X5 cm Stage 3 pressure ulcer on her left heel that is completely covered by a dry, intact dressing due to be changed tomorrow. States it is much improved after 6 weeks home care nursing. How would you score Jane’s Braden Pressure Ulcer Risk and how would you document the Pressure Ulcer? Key Points : 1.Standard risk for developing a new PU but came in with a healing PU that cannot be fully assessed until dressing is changed. Pt. able to provide some description of PU but other assessment deferred at present. 2.Skin Integrity Problem identified, PU wound started, and Pressure Ulcer Stage 3 Care documented. 3.Skin care measures being taken to prevent any additional skin care problems are documented.

Implications for Overall Plan of Care Plan of care should address risk factors for skin impairment in order to individualize plan for patient. If nutrition risk factor, what will you do to support improved nutrition -- TPN, Nutritional Supplements, Assist with feeding, etc. If activity or mobility risk factor, what measures could you initiate to address – appropriate pressure redistribution devices, address fatigue by clustering activities, appropriate smooth moves equipment for repositioning, etc. If moisture risk factors, how might you address – barrier sprays/creams, more frequent toileting or linen changes, etc. Focus on actions you as a nurse can take that directly impact outcomes for the patient. Samples for Patient with moisture, activity, & friction/shear risk: Plan Priorities: ensure condom catheter not leaking; cluster activities to conserve strength; use slippery sheets to reposition & foam to both elbows