A nurse is assessing a patient with paraplegia using the Braden Scale. The patient reports occasional moist skin and poor appetite, and frequently slides down in their wheelchair. What is the most likely Braden score range for this patient?

A. To prevent shearing of the patient's skin: When a patient is pulled or dragged across a sheet, the deeper tissues (bone and muscle) are stationary while the skin moves, leading to shear injury—one of the primary mechanisms for Deep Tissue Pressure Injuries (DTPIs). Using a lift device raises the patient completely, eliminating this destructive shearing and friction force.

B. To make the repositioning process faster:While a lift device may be efficient, patient safety and skin protection are the clinical priorities, not speed.

C. To prevent the nurse from straining their back: This is an extremely important benefit for nurse safety and injury prevention, but the primary reason the intervention is implemented in the patient's plan of care is for the direct therapeutic benefit of protecting the patient's skin integrity.

D. To ensure the patient is positioned comfortably: This is a secondary benefit. While comfort is considered, the lift device's essential function is mechanical protection of the skin and underlying tissues.

A. Sanguineous drainage: Sanguineous drainage is fresh, bright red blood.

B. Serosanguineous drainage: Serosanguineous drainage is a mixture of serous fluid (pale, watery) and sanguineous fluid (blood), resulting in a thin, watery, pale pink or light red color. This is a common, normal finding in the inflammatory and proliferative phases of healing.

C. Purulent drainage: Purulent drainage is thick, opaque, and colored (yellow, green, or brown) with a foul odor, indicative of infection.

D. Serous drainage: Serous drainage is clear, thin, and watery, like plasma. The presence of a pink tint indicates blood, classifying it as serosanguineous.