[Answered]: Directions: Use the Braden Scale to assess the…

Directions: Use the Braden Scale to assess the following patient’s level of risk for development of pressure ulcers. SENSORY PERCEPTION Definition: ability to respond meaningfully to pressure related discomfort 1. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation OR limited ability to feel pain over most of body. 2. Very Limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment which limits the ability to feel pain or discomfort over 1⁄2 of body. 3. Slightly Limited Responds to verbal commands, but cannot always communicate discomfort or the need to be turned OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. 4. No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. Prompt: • Your patient is 78-year-old female admitted from the long-term care facility for abdominal surgery. She is alert and oriented x 4. • Past medical history: Diabetes Mellitus, Heart Failure and Obesity. • She has a Jackson Pratt (JP) drain placed in the right upper quadrant (RUQ) of the abdomen to drain fluid from the surgical incision. The output is serosanguineous, ranging from 30-50cc every shift. It is sutured in place and has a dry gauze dressing over the insertion site. • She has some neuropathy (sensory impairment) in her feet due to Diabetes. • She has occasional urine leakage while in bed. Linens are changed daily and usually one extra time each day due to the moisture. • Her activity is limited and she cannot bear weight on her own. She is only able to transfer to chair with assistance. • She can make minor changes in body position while in bed but requires the assistance of one person when turning in bed. • She has had a decreased appetite and takes in only about 1⁄2 of her meals offered. She usually drinks a dietary supplement daily. • She occasionally slides down in bed and during movement and her skin tends to rub against the sheets.