The nurse is caring for four patients during a shift. Which of the following patients is at greatest risk for developing a pressure ulcer?
a. The patient who is bedridden, but who turns himself randomly
b. The patient whose Braden Scale score is 8
c. The patient who can ambulate to the bathroom independently
d. The patient whose Braden Scale score is 18
B
Given the overall score on the Braden Scale, the patient will fall within one of these categories: mild risk, 16 to 18; moderate risk, 13 to 14; or high risk, 9 or less. Use these risk scores to plan care by looking at the individual risk factors that place the patient at risk and developing a care plan to decrease or eliminate the identified risk factors. Immobility often restricts the patient's ability to change and control body position, thus increasing pressure over bony prominences. Patients who can turn themselves are at less risk than those who cannot.
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