The nurse has completed the assessment of an elderly patient with the Braden Scale. The calculation of the patient's score is very low. This information suggests which of the following to the nurse?
1. The patient is at low risk for skin breakdown.
2. The patient is independent with activities of daily living.
3. The patient is at high risk for skin breakdown.
4. The patient is well-hydrated.
3
Rationale: The Braden Scale for Predicting Pressure sores is used in most acute care settings to assess for skin breakdown. The subscales of sensory, perception, moisture, mobility, nutrition, and friction and shear, are scored based on descriptive criteria. A lower score on the assessment tool indicates a higher risk for pressure sore development. The patient is not at a low risk for skin breakdown. Because of the different subscales within the Braden Scale, the patient is most likely not independent with activities of daily living or well-hydrated.
Analyzing
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3-9. Describe common geriatric assessment tools.
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