Braden scale is the assessment tool used for predicting the severity of the?

SCTIMST Staff Nurse - 2015 (Set-B)

Fundamental of Nursing

Easy

Appeared in: SCTIMST Staff Nurse - 2015 (Set-B)

Explanation

The Braden Scale is a standardized, evidence-based tool specifically designed to assess a patient's risk for developing pressure ulcers.
It evaluates six distinct risk factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
The resulting score helps nurses to implement targeted preventative strategies for at-risk patients, rather than measuring the severity of an existing condition.
A lower score on the Braden Scale corresponds to a higher risk, prompting more intensive nursing interventions to maintain skin integrity.

Option A: Brain oedema (swelling) is a neurological condition. Its assessment involves neurological examinations, monitoring intracranial pressure (ICP), and brain imaging (CT/MRI), not a skin risk assessment tool.
Option C: Myocardial ischemia is a cardiac condition involving reduced blood flow to the heart. It is diagnosed using an electrocardiogram (ECG), blood tests for cardiac markers (e.g., troponin), and sometimes angiography.
Option D: Cerebral ischemia is a neurological event (stroke) caused by insufficient blood flow to the brain. Diagnosis relies on urgent brain imaging (CT or MRI) and a rapid neurological assessment.

Clinical Relevance

Nursing practice connection: Use the key finding related to Use of the Braden Scale for pressure ulcer risk assessment to guide bedside assessment, documentation, and the next nursing action.
The Braden Scale is a fundamental tool in nursing practice for proactive care. It shifts the focus from treating pressure ulcers to preventing them, which is crucial for patient safety and quality of care.
Regularly using the Braden Scale (e.g., on admission, daily, and with any change in condition) allows nurses to tailor care plans, such as turning schedules, nutritional support, and use of pressure-relieving surfaces.
What if? If a patient's Braden score drops from 18 (mild risk) to 12 (high risk) after surgery, the nursing priority shifts from routine monitoring to implementing aggressive prevention strategies. This would include a strict 2-hour turning schedule, consultation with a dietitian, and potentially upgrading to a pressure-redistribution mattress.

How to Approach the Question

First, identify the core subject of the question, which is the 'Braden Scale'.
Recall or deduce the primary purpose of this specific clinical assessment tool.
Evaluate the given options to see which condition aligns with the tool's purpose.
Option A (Brain oedema), C (Myocardial ischemia), and D (Cerebral ischemia) are acute medical conditions related to the brain and heart, assessed by diagnostic imaging and specific neurological/cardiac tests.
Option B (Pressure Ulcer) is a condition related to skin integrity, often in patients with limited mobility.
Conclude that the Braden Scale, which assesses factors like mobility, moisture, and nutrition, is logically used to predict the risk of pressure ulcers.

Concept Tested & Keywords

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E6 Nursing Fundamentals Taylor p. 562-564

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 pp. 110-112, 108-110