Braden Scale Assessment Tool for Predicting Pressure Ulcer Risk(copyright Barbara Braden and Nancy Bergstorm, 1988) | Sensory PerceptionAbility to respond meaningfully to pressure-related discomfort | 1. Completely LimitedUnresponsive (does not moan, flinch, or grasp) to painful stimuli caused by diminished level of consciousness or sedationOr Limited ability to feel pain over most of the body. | 2. Very LimitedResponds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessnessOrHas a sensory impairment which limits the ability to feel pain or discomfort over ½ of the body. | 3. Slightly LimitedResponds to verbal commands, but cannot always communicate discomfort of the need to be turned.OrHas some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. | 4. No ImpairmentResponds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. | MoistureDegree to which skin is exposed to moisture. | 1. Constantly moistSkin is kept moist almost constantly by perspiration, urine, etc. . . Dampness is detected every time a patient is moved or turned. | 2. Very moistSkin is often, but not always moist. Linen must be changed at least once a shift. | 3. Occasionally MoistSkin is occasionally moist, requiring an extra linen change approximately once a day. | 4. Rarely MoistSkin is usually dry; linen only requires changing at routine intervals. | Activity Degree of physical activity | 1. BedfastConfined to bed. | 2. ChairfastAbility to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. | 3. Walks occasionallyWalks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair. | 4. Walks frequentlyWalks outside room at least twice a day and inside room at least once every two hours during waking hours. | MobilityAbility to change and control body position. | 1. Completely immobileDoes not make even slight changes in body or extremity position without assistance. | 2. Very LimitedMakes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. | 3. Slightly LimitedMakes frequent though slight changes in body or extremity position independently. | 4. No LimitationsMakes major and frequent changes in position without assistance. | Nutrition | 1. Very poor; Never eats a complete meal; rarely eats more than 1/3 of any food offered; eats 2 servings or less of protein (meat or dairy products) per day Takes fluids poorly; does not take a liquid dietary supplement OR Is NPO and/or maintained on clear liquids or IVs for more than 5 days | 2. Probably inadequate; rarely eats a complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day; occasionally takes a dietary supplement OR Receives less than optimum amount of liquid diet or tube feeding | 3. Adequate; eats over half of most meals; eats a total of four servings of protein (meat, dairy products) each day. Occasionally refuses a meal but usually takes a supplement if offered OR Is on tube feeding or total parental nutrition regimen that probably meets most of the nutritional needs | 4. Excellent; Eats most of very meal; never refuses a meal; usually eats a total of four or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation | Friction & Shear | 1. ProblemRequires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction. | 2. Potential ProblemMoves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. | 3. No apparent ProblemMoves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair. | TOTAL SCORE:14 |

Glasgow Coma Scale | | | | | | | Eye opening to: | Spontaneous=4 | | | | | | | | Verbal command=3 | | | | | | | | Pain=2 | | | | | | | | No response-1 | | | | | | | | | | | | | | | Verbal Response: | Oriented, converses=5 | | | | | | | | Disoriented, converses=4 | | | | | | | | Uses inappropriate words=3 | | | | | | | | Incomprehensible sounds=2 | | | | | | | | No response-1 | | | | | | | Motor response to: | Verbal command=6 | | | | | | | | Localized pain=5 | | | | | | | | Flexes and withdraws=4 | | | | | | | | Flexes abnormally (decorticate)=3 | | | | | | | | Extends abnormally (decerebrate)=2 | | | | | | | | No response-1 TOTAL: 14 | | | | | | | |

Medications | Name: Tonya Hamilton_____ Client Initials: __S.H.__ Date: 7/08/2014_week 1__
Age: _76 Gender: Female_ Unit: 2nd floor_ Admin Date: 7/3/14__________
Diet: _liquid__________________ Activity: Reposition, Bed rest, elevate head of bed__________________
Code Status: Full code______ Allergies: NKDA, NKFA______________________ | Labs | Please see medication list | | Please see lab list | | | | | Admitting Dx/Chief Complaint | | | Pt. transferred from UNC 7/3/14.Pt. status post right parietal intracerebral hemorrhage with encephalopathy w/acute respiratory failure, currently on vent.Pt. was admitted to try to wean off her ventilator, previous attempts unsuccessful. Pt. presented positive for MRSA; Pressure Ulcer: Sacrum Stage III on admission. Perineal dermatitis perineum / buttocks.Pt. present with CV line r-portacath - present on admission. | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Past Medical and Surgical History | | Treatments | Multiple intracranial hemorrhagesCerebrovascular accidentSeizure disorderCOPDBreast cancer, status post chemotherapyHypertension - HTNHyperlipidemia7/3/14 – tracheostomy tube – present on admitDiastolic dysfunctionStrokeMRSA | | Wound careNutritional supportO2 Therapy | | | | | | | | | | | | | | | | | | | Medication | Dose | Route | Frequency | Specific reason pt. is taking | Nursing considerations & Contradictions (Make sure to include no less than 5 critical things you must remember when giving this medication) | hydrochlorothiazide | 25 mg | tube | Daily | HTN | (Roth, 2013, pg. 597). | haloperidol | 5 mg | tube | q 6 h PRN daily | | | iron/vit b12 / int fac | 1 | PO | Daily | | | propranolol hcl | 40 mg | tube | q 8 hours | | | hydralazine | 5 mg | IV push | q 6 h PRN | | | Isosource 1.5 | 45 ml | tube | Per hour cont. | Nutritional feeding | This is intending to keep her nutritional values stable | zinc oxide / menthol | 1 apply | Topical | Daily | | | collagenase | 1 apply | Topical | Daily | | | atorvastatin | 10 mg | tube | q 24 h daily | | | escitalopram oxalate | 10 mg | tube | daily | | | losartan | 100 mg | tube | daily | Cardiac | | amlodipine | 10 mg | tube | daily | Cardiac | | omeprazole | 20 mg | tube | daily | | | levetiracetum | 750 mg | tube | q 12 h | | | lorazepam | 0.5 mg | tube | q 12 h | | | ferrous sulfate | 300 mg | tube | q 12 h | | | ascorbic acid | 250 mg | tube | q 12 h | | | trazodone | 50 mg | tube | q 12 h | Sleep | | chlorhexidine CHG 0.12% | 0.5 oz | dental | q 12 h | | | Ipratropium bromide / albuterol sulfate | 3 ml | Inhalation | q 6 h | | | Acetaminophen | 650 mg | tube | q 6 h PRN | | |

Lab Test | Date & Value | Date & Value | Interpretation/Significance & Trend | | | Iron Binding Capacity Panel | 7/5/14 | 7/8/14 | All WNL. | | Iron 67 ug /dl; Total iron binding capacity 297 ug / dl; Percent saturation – 23%; ULBC 230 ug / dl. | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Diagnostic Test | Results | Date | Interpretation/Significance & Trend | | | No diagnostic tests given to date. | | 7/8/14 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Nursing Diagnosis:
The Problem: Patient has a Stage III, Sacrum, Pressure ulcer (Impaired skin integrity) | | | Related to: (Not medical diagnosis)Related to decreased immobility, age, poor circulation, moisture, and chronic disease state. | | As evidenced by Subjective Assessment
Redness, blisters, open lesion involving the dermis, open lesion which involves bones and joints, and drainage of pus. | Objective AssessmentPatient is non-responsive, non-verbal, but able to shake her head yes and no. Was able to read lips. | | | Expected outcomes:
Timed and measurablePatient will maintain healing process of her stage III, sacrum, pressure ulcer for the next two weeks. | | Nursing Intervention At Least 5 number each one | Rationale for each intervention number with corresponding previous intervention | Evaluation and Modification for each intervention. Number with corresponding intervention | | | | 1. Reposition patient. 2. Determine the risk factors leading to the pressure ulcer formation: age, mobility, disease. 3. Observe the skin integrity on the bony prominences. 4. Evaluate for use of support surfaces. 5. Prevent overexposure to moisture such as from urine or perspiration. | 1. This is to protect against the adverse effects of forces such as shear, friction, and pressure. 2. Elderly patient’s skin is less elastic and has less moisture making it more prone to skin impairment. 3. The areas where the skin are stretched are: sacrum, Trochanters, scapulae and elbows. These are the areas where the highest skin breakdown are. There is a possibility of skin ischemia due to compression of blood vessels. | 1. Patient will be repositioned every two hours for comfort and to avoid skin breakdown. 2. The patient will be able to manifest signs of healing and reduction of pressure ulcer within two weeks. 3. The patient will be able to prevent future pressure ulcers within a week. 4. Starting immediately, we will use pillows, form wedges and pressure reducing devices in patient’s bed. | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Nursing Diagnosis:
The Problem: | | Related to (not medical diagnosis) | | As evidenced by Subjective Assessment: | Objective Assessment: | | | Expected outcomes:
Timed and measurable | | Nursing Intervention At Least 5 number each one | Rationale for each intervention number with corresponding previous intervention 4. Elevate head of bed at the lowest degree to reduce friction, shear and pressure. 5. This can prevent accumulation of bacteria therefore keeping away from further infection. | Evaluation and Modification for each intervention. Number with corresponding intervention 6. Inspect and monitor the site of the skin impairment once a day for redness, swelling, color changes, pain, warmth or any other signs of infection. | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |

My Thoughts & Reflections from Clinical
Name:
Clinical Week: Week 1
Area: Second Floor / Kindred Hospital
Clinical Instructor: Ms. Rhoney
Any new skills attempted or acquired today:
I did a complete bed change for a patient who was in the bed next to my patient; a head to toe assessment on my patient, while patient had a trach and on a ventilator.

Activities or interactions with patients/staff/family and how would this change nursing care?
My overall experience with the staff, was a pretty good experience. My nurse, Jordan, was amazing and actually showed me things that I had particular questions about. My patient did not have any family present during my clinical experience. My interaction with my patient was almost non-existent, since she was non-responsive for most of the day and non-verbal. When I returned from lunch, my patient was awake and would nod her head yes and not when I would ask her something. However, I did have a really hard time trying to read her lips when she was trying to tell me something. Since I was not understanding her, I went and grabbed Jordan, the nurse, and brought her into the room, to help me understand what Ms. Holt was trying say.

Observations, feelings or reactions to specific events:
I was really nervous going into my first day of my clinical experience. I guess a huge factor was not knowing what to expect. I did have a rather challenging patient because my patient for the most part was non-responsive and I wasn’t sure how to deal with that at first. I know going into nursing, it is a challenging profession where you may encounter a lot of sadness. My experience for this day was I was overwhelmed with sadness, seeing all these patient’s on trachs, ventilators, being immobile. I just wanted to be able to cure them all.

Insights into the patient’s experience:
I was overcome with a sadness for my patient at first because she reminded me a lot of what my mother went through before she passed away. I felt a sense of helplessness for patient, as she is so limited to what she is able to do. For the most part, she is non-responsive and is just resting. I did not have a lot of interaction with my patient. I spoke to her and explained everything to her but she slept for most of the day. I was able to ask her in the afternoon if she was comfortable and if she had any pain.

New areas of learning for me:
One new area of learning for me was with the respiratory team and the CNA. I got to observe a trach being replaced on my patient. I also observed how they repositioned the patients while on the ventilators and trachs. I observed wound care on another student’s patient.

How has this experience added to my understanding or my practice of nursing? Has it altered my definition of care?
I learned how difficult and how careful you have to be with trach patients. This experience has helped me to retain the knowledge of caring for a patient with a trach and ventilator and how limited or immobile they or can be. I realized how difficult it can be to understand your patient and what they may be asking you for or they may need.

References:

Ackley, B. J., & Ladwig, G. B. (2013).Nursing diagnosis handbook: an evidence-based guide to planning care (10th ed.). Maryland Heights, Mo.: Mosby. Pagana, K. D., & Pagana, T. J. (2013).Mosby's diagnostic and laboratory test reference (11th ed ed.). St. Louis, Mo.: Mosby Elsevier. Roth, L. (2013). Mosby's Drug Guide for Nursing Students, with 2014 Update (10th ed.). London: Elsevier Health Sciences.