Author Question: The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the ... (Read 55 times)

iveyjurea · **on:** Jul 23, 2018

The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission. The nurse has implemented interventions for this nursing diagnosis.

Upon reassessment, which Braden score would be the best sign that the risk for skin breakdown is decreasing?
a. 12
b. 13
c. 20
d. 23

Question 2

The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of care understands the need for a multidisciplinary approach. The nurse evaluates the need for several consults.

Which of the following should always be included in the consults? (Select all that apply.)
a. Registered dietitian
b. Enterostomal and wound care nurse
c. Physical therapist
d. Case management personnel
e. Chaplain
f. Pharmacist

heyhey123 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: D
The Braden scale is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The total score ranges from 6 to 23, and a lower total score indicates a higher risk for pressure ulcer development. The cutoff score for onset of pressure ulcer risk with the Braden scale in the general adult population is 18. The best sign is a perfect score of 23.

Answer to Question 2

ANS: A, B, C, D
A registered dietitian is useful in working with the nurse to determine a meal plan that will support wound healing. An enterostomal or wound care nurse specializes in caring for the needs of the patient with wounds. Physical therapy is concerned about the mobility of the patient and can assist an immobile patient to progress toward mobility and decrease the risk for pressure ulcers. Pressure ulcers take a long time to heal and usually require continued therapy in the home. Case management personnel are useful in obtaining care for the patient outside the home. If the patient has a spiritual need, the chaplain can assist. If the patient has a need associated with medications, the pharmacist can assist. However, chaplains and pharmacists usually are not part of the wound care multidisciplinary team, unless a special need arises.