Answer the 1- 4 question at the

Answer the 1- 4 question at the bottom. Logan Kovac is a 76-year-old client admitted from the hospital 6 weeks ago for ongoing rehabilitation and care after experiencing a syncopal episode and fall at home. The client/patient sustained a closed head injury with a subdural hematoma at that time which has left the client/patient with generalized weakness and difficulty with speech and language. Previous Medical History: Hypertension, Diabetes, Parkinson’s disease. Allergies: Iodine Resuscitation: Full Code Fall Risk: High Ht/Wt: 5’8″/135 lbs Vital Signs have been within normal limits: 97.3 Tympanic, Pulse 80 bpm, Resp Rate 16 breaths/min, BP 140/80 mm Hg Right Arm, Lying. Pain: Faces Cardiac: S1 and S2 auscultated, regular. Respiratory: Clear breath sounds auscultated anterior and posterior; no adventitious breath sounds auscultated. Neurological: Alert and oriented to person only, non-verbal. Restless in bed at times. Gastrointestinal: Poor appetite, has been only taking small bites of a soft low sodium diet (ate only 25% of last 2 meals). Last BM was 2 days ago. It was hard and brown. Bowel sounds are normoactive in all 4 quadrants. Genitourinary: Incontinent of urine Musculoskeletal: Unable to bear weight and has generalized weakness- requires 2 people for transferring to wheelchair and to reposition in bed. Integumentary: Skin warm, dry, and intact. Using the data included in this ISBARRQ report and what you can assess/observe in this client/patient, complete the following: 1. Identify areas most at risk for skin breakdown in this client/patient. 2.Complete the Braden Scale Risk Assessment for this client to identify the level of risk for skin breakdown. 3.Consider additional factors that contribute to the development of pressure ulcers/skin breakdown for this client/patient. 4.Which nursing actions should you include in this client/patient’s plan of care?

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