Chapter 2: Patient Assessment
2.12 Head-to-Toe Assessment: Integument Assessment
Critical Thinking Exercises: Questions, Answers, and Sources / References
Critical thinking questions are in bold type, and the answers are italicized. Additional resources or references are provided below.
- Identify the six components of the Braden Scale that suggest risk of pressure injury.
- Activity: Degree of physical activity
- Nutrition: Usual food intake pattern
- Moisture: Degree to which skin is exposed to moisture
- Mobility: Ability to change and control body position
- Friction/Shear: The force of rubbing (friction) and the force of gravity from the patient’s weight bearing down on a surface, and the resistance created when attempting to move a patient over that surface (shear).
- Sensory Perception: Ability to respond meaningfully to pressure-related discomfort
Chen, H., Cao, Y., Zhang, W., Wang, J., Huai, B. (2017). Braden scale (ALB) for assessing pressure ulcer risk in hospital patients: A validity and reliability study. Applied Nursing Research, 33. pp. 169-174. https://doi.org/10.1016/j.apnr.2016.12.001
2. In five of those components, provide two possible preventative strategies to reduce risk of pressure injury.
Component Contributing to Risk of Pressure Injury
|Friction / Shear||
Registered Nurses’ Association of Ontario (RNAO). (n.d.). Nursing best practice guidelines: Nutrition and hydration. https://bpgmobile.rnao.ca/content/minimizing-risk-entrapment
Registered Nurses’ Association of Ontario (RNAO). (n.d.). Nursing best practice guidelines: Proper positioning, transferring and turning techniques. https://bpgmobile.rnao.ca/content/timelines-when-pressure-ulcer-can-develop-specific-clinical-setting
Registered Nurses’ Association of Ontario (RNAO). (n.d.). Nursing best practice guidelines: Risk assessment and prevention of pressure ulcers. https://bpgmobile.rnao.ca/guideline-content/9
Registered Nurses’ Association of Ontario (RNAO). (n.d.). Nursing best practice guidelines: Skin integrity. https://bpgmobile.rnao.ca/content/risk-and-related-interventions
Sample Learning Activity
- Ask students to complete a Braden Scale assessment on a client they are caring for in practice, and document it on a Braden Scale assessment form.
British Columbia Provincial Nursing Skin and Wound Committee. (2014) Guideline: Braden Scale for Predicting Pressure Ulcer Risk in Adults and Children. https://www.clwk.ca/buddydrive/file/guideline-braden-risk-assessment/
- Ask students to begin developing a plan of care related to reducing risk of pressure injury.
The author suggest(s) not focusing on NANDA terminology because Schools of Nursing (and nurses) don’t all speak that language. Rather, the focus should be on strategies intended to address the issue and identifying how the nurse will know that the strategies are working.
Issue Contributing to Risk of Pressure Injury
Evaluation (Is This Working?)
|Poor nutritional intake||
|Patient is eating 50-75% of their meals.|
|etc. etc. etc.|