Question

J.L. has had decreased appetite in the last week, eating only small amounts of each meal. He is repositioned in bed by the CNAs every two hours and is assisted to his chair by Hoyer lift for two-hour increments 2-3 times a day as tolerated. Assess J.L. using the Braden Scale: https://consultgeri.org/try-this/general-assessment issue 5.pdf Braden scale scoring Rationale for scoring Sensory Perception Moisture Activity Mobility Nutrition Friction and Shear Total score: Risk category:

Answer 1

#. Braden score - 15 ( mild risk )

- Sensory perception is 4 (No impairment)

Rationale - Responds to verbal commands . Has no sensory deficit which would limit ability to feel pain or discomfort .

- Moisture is 4 ( Rarely moist )

Rationale - Skin is usually dry , linen only requires changing at routine intervals.

- Activity is 2 ( Chairfast)

Rationale - Ability to walk is severely limited . Cannot bear down weight , must be assited into chair or wheelchair .

- Mobility is 3 ( very limited )

Rationale - Makes occasional slight changes in body position but unable to make frequent changes independently .

- Nutrition is 1 ( very poor)

Rationale - Because she is eating less than 1/2 of a meal .

- Friction and shear is 1 ( problem )

Rationale - Requires moderate to maximum assistance in moving