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Day 3 0830: VS: T 36.8° C (98.2° F), BP 126/68, P 64 and regular, R 20 and unlabored. O2 saturation 96% on RA. Denies pain. T.M. is A&Ox4, PERRLA. Lungs clear. Apical pulse is 64 and regular. Abdomen is soft and nontender. BS present in all four quadrants. Skin warm and dry. Braden score 16. Wound on right buttocks 3.2 cm × 2.8 cm × 1 cm deep. Wound bed is red with moderate amount of exudate. No tunneling or undermining. Wound cleansed with sterile NS. New hydrocolloid dressing applied. Pedal pulses 2+ bilaterally. SCDs in place on both legs. 4" healed scar on the front of the left shin, which T.M. states is from the surgery following the accident. Lower extremities are flaccid. Unable to feel sharp or dull objects touching his legs. Weight 64.5 kg (142 lb). Height 180.3 cm (71 in). Patient states "I watch what I eat because I don't want to get too heavy to lift myself during transfers." T.M. states, "I feel sad that this has happened to me. I struggled after the accident, but I was finally doing well, working hard strengthening my upper body, mostly taking care of myself, and working from home." His wife helps him with some of his care and does ROM exercises on his legs every night before they go to sleep. Get the instant assignment help. T.M. says that his wife is very supportive and has visited in the evenings while he has been in the hospital. Her parents live nearby and help with childcare when needed. What is a Braden scale and what does a score of 16 mean?
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