Braden Score: Case Studies 1 & 2

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Case study # 1•75-year-old male with Non-Hodgkins

lymphoma, Alert and oriented

•Height 5’9”, Weight 160 lbs.

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Braden Score

•Moisture 3

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Braden Score

•Activity 2

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Braden Score

Nutrition 2

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Braden Score

•Friction/Shear 2

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Braden ScoreCase Study # 2

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Case study #2

•Mrs. West is a 79- year old widowed female admitted to the nursing home after a right hip fracture.

•She lives alone. Her daughter lives close by and visits frequently.

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Case study #2

•Past Medical History includes:▫Hypertension▫DM Type II insulin dependent▫Anxiety Disorder▫Osteoarthritis

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Case study #2

•During hospitalization:▫Her anti-hypertension medications were

restarted and adjusted.▫After surgical hip pinning, PT and OT were

ordered on the first day post-op for exercises, ROM, transfer, and ADL training. She refused therapy due “I just don’t want to

get out of bed yet”.

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Case study #2

Post-Op day 1•PT reports that when she allows them to

get her out of bed she requires assistance of two for safe transfers. OOB usually only once a day. Staff often find her slumped in the chair and have to put her back to bed.

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Case study #2•She reports pain in right hip 5/10 and 2/10

in left knee from arthritis.•She is refusing any pain meds , “its too

much trouble for those little girls, they are busy.”

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Case study #2

•She only consumes 50% of her food at each meal. She able to feed herself.

•Her height and weight are:▫63 inches (5 foot ,3 inches)▫105 pounds

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Case study #2

•She is continent of urine but has occasionally has been found to be wet when staff have turned her.

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Case study #2•Preferred position is supine with head of

bed elevated with pillow under right leg.

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Case study #2

Post-Op day •Night shift nurse noted that there is a 1.0

CM X 2.0 cm non-blanchable reddened area on coccyx.

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Case study #2

Discharge Day•She is discharged to NH for PT/OT

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Braden Score

What is the total score?

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Case study # 1

•Spends most of the day in bed. Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

•Occasionally slides down to foot of bed,

requiring some assistance to move back to the top.

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Case Study: # 2

•Able to walk a short distance to the chair with assistance

•Hgb = 8.5, Serum Albumin 3.1

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Case Study: # 2 •Incontinent of stool

•Continent of urine – uses urinal as needed

•Skin occasionally moist from incontinence

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Case Study # 2•Admitting Orders:

▫Tube feeding formula 400cc q 4 hours per PEG

▫Dietician consult for tube feeding recommendations

▫Up in chair daily

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Case study # 2

Using the Braden Scale, what is Mr. W.G.’s sensory perception score?

A. 1 (Completely Limited)B. 2 (Very Limited)C. 3 (Slightly Limited)D. 4 (No Impairment)

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Sensory Perception

•4 (No Impairment)

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Case study # 2

Using the Braden Scale, what is Mr. W.G.’s moisture score?

A. 1 (Constantly Moist)B. 2 (Very Moist)C. 3 (Occasionally Moist)D. 4 (Rarely Moist)

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Moisture

•3 (Occasionally Moist)

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Case study # 2

Using the Braden Scale, what is Mr. W.G.’s activity score?

A. 1 (Bedfast)B. 2 (Chairfast)C. 3 (Walks Occasionally)D. 4 (Walks Frequently)

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Activity

•2 (Chair fast)

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Using the Braden Scale, what is Mr. W.G.’s mobility score?

A. 1 (Completely Immobile)B. 2 (Very Limited)C. 3 (Slightly Limited)D. 4 (No Limitations)

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Mobility score

•2 (Very Limited)

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Using the Braden Scale, what is Mr. W.G.’s nutrition score?

A. 1 (Very Poor)B. 2 (Probably Inadequate)C. 3 (Adequate)D. 4 (Excellent)

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Nutrition

•3 (Adequate)

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Braden Score

•Sensory 4

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Case study # 1

Using the Braden Scale, what is Mr. W.G.’s friction and shear score?

A. 1 (Problem)B. 2 (Potential Problem)C. 3 (No Apparent Problem)

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Friction and Shear

•2 (Potential Problem)

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Case study # 1

Based on Mr. W.G.’s total Braden Scale Score, indicate his level of risk for developing a pressure ulcer.

A. 9 or less = Very high riskB. 10-12 = High riskC. 13-14 = Moderate riskD. 15-18 = Mild riskE. 19-23 = Generally not at risk

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Based on Mr. W.G.’s total Braden Scale Score, indicate his level of risk for developing a pressure ulcer.

A. 9 or less = Very high riskB. 10-12 = High riskC. 13-14 = Moderate riskD. 15-18 = Mild riskE. 19-23 = Generally not at risk

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