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Mrs. Dillard, a 70-year-old woman from a nursing home was admitted to the hospital for dehydration and hyperglycemia. Her past medical history includes CVA, diabetes, fracture to the left hip. On admission her blood sugar was 369 mg/dl, WBC-12,000, Albumin- 3.4g/L. She is non-verbal and responds to painful stimuli by moaning, is diaphoretic, incontinent of urine and stool, immobile and requires assistance with mobility and repositioning. On admission her skin assessment revealed an open area to her coccyx measuring 5cmx5cmx2.3cm, 50% slough, large amounts sanguineous exudate with malodorous odor, peri-wound has some redness, but does not blanche. She is on antibiotics and IV Fluids but is not eating. Based on Mrs. Dillard Braden score, what are her risk factors for developing further skin breakdown? Decreased mobility Friction and shear Nutrition Moisture Bed bound status Decreased activity.
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