Braden Scale

Kyle Michaels is a 55 y.o. male with history of type II Diabetes Mellitus, Hypertension, Hyperlipidemia, Coronary Artery Disease, and Diabetic Foot ulcer, presents to the emergency department with chief complaint of worsening sacral ulcer. Patient resides at home and was receiving home health wound care and eventually progressed into needing IV antibiotics and was suggested to go to the ED for worsening infection.

Inpatient Hospital Room

1. Accurately complete a Braden Scale assessment based on patient cues.
2. Interpret the Braden score and correctly determine the patient's level of risk.
3. Identify the subscale(s) most contributing to risk and tailor interventions accordingly.
4. Apply appropriate nursing interventions based on each Braden subscale score.
5. Document findings and interventions in accordance with facility policy.

1. Nurse identifies and documents the correct Braden subscale scores based on assessment findings.
2. Nurse classifies the overall risk level correctly and implements appropriate prevention measures.
3. Nurse explains rationale behind each intervention linked to the Braden subscale.
4. Nurse initiates documentation and appropriate escalation (e.g., wound care consult for moderate/high risk).
5. Nurse demonstrates patient education on risk factors when applicable.