OBJECTIVE

STRUCTURED
CLINICAL
EXAMINATION (OSCE)
SCENARIO
Mrs. Agustin, an 87 year old woman, who has been diagnosed with Guillain Barre
Syndrome (GBS). She is experiencing muscle weakness, and has developed some
degree of impairment in her leg, which limits her ability to feel pain on that side of
her body. Her skin is dry, intact and rarely moist. She occasionally walks with
assistance, but only for short distances, since she struggles to maintain an upright
position. She makes major and frequent changes position in her position throughout
the day. She enjoys most of the meals served. She eats adequately, finishing half of
most meals. She maintains a relatively good position but occasionally slides down.
1.What is the Braden Score?
2.What are the most vulnerable areas of pressure risk?
3.What are the signs that may indicate pressure ulcer development?
BRADEN SCALE SCORING
Sensory Perception 3 some sensory impairment

Moisture 4 dry, intact, rarely moist

Activity 3 walks with assistance

Mobility 4 major frequent position

Nutrition 3 half meal

Friction and Shear 2 good position

___________________
19
1.Heels, sacrum, ischial tuberosities (buttocks), elbow, temporal
region of the skull, shoulders, femoral trochanters (hips), back of
head, toes, ears, spine

2.Persistent erythema (flushing of the skin), non-blanching

hyperemia (discoloration of the skin that does not changed when
pressed), blisters, discoloration, localized heat, localized edema,
localized induration (abnormal hardening), purplish/bluish
localized areas, loczalized coolness if tissue death has occurred.