The Braden Scale: A Dynamic Tool?

The Braden Scale is a fixture in wound care circles that helps clinicians predict pressure ulcer risk. It is also the source of growing controversy. The problem seems to be that with continually increasing use, practitioners are discovering its limitations. A February 2012 article provides a meta-analysis of its use in surgical patients and upcoming articles in OWM will reflect on its ability to accurately assess risk among ICU patients. Some studies are finding that the overall Braden Scale score is not as informative as particular subscores.

The Braden Scale has been tweaked for use in children (the Braden-Q). As we discover more about pressure ulcer risk factors (eg, serum albumin levels may not provide dependable implication for risk), it is not unreasonable to anticipate clinicians making further modifications to this tried-and-true tool in wound care.

Cyberchondria: What? Me worry?

I had to laugh at a condition described on a recent news report. Cyberchondria is a term first used in a 2001 article published the UK newspaper The Independent to describe “the excessive use of internet health sites to fuel health anxiety” (it also was first used by the BBC that same year). Several studies have been conducted, confirming the prevalence of this disorder and its tendency to escalate concern about common symptoms and increase misuse of medical information (google cyberchondria for a full description of the studies and their findings).

Undoubtedly, web crawls exponentially multiply the number of resources for laypersons to access the medical universe. But for symptom-scared folks like me who, despite spousal protest, purchased (and hid) a copy of the Merck Manual; who as a child regularly consulted a big, green medical text (the name escapes me) with those plastic overlays of the body’s “systems” in the centerfold; who will tell you that every headache is a potential brain tumor and every wound harbors gruesome infection, even as the editor of a medical journal, cyberchondria is not news. It is confirmation — almost sad —that as much as we try to learn more about ourselves, we seem to feel we have to seek answers on our own and not ask our providers— a statement on bedside manner, time clinicians allot patients, and trust. It’s like the commercial where the woman states she read something on the Internet, so it must be true. So NOT true.

In all honesty, this does not seem to be as much a nurse issue as a physician issue. But perhaps you can remind the doctors with whom you work: if I take time to come see you, assume all is not well. Ask me. Look at me (not your drop-down EMR menu). If you are running late, you probably had kept me waiting, so don’t rush in and out. Take your time. And if you are too pressed to offer lengthy explanations, please direct me to other professionals, provide written materials (handouts), or offer reliable worthwhile websites.

Risk, Not Excuses

My cousin the podiatrist has noticed an uptick in the number of wounds he treats. When I asked what exactly he is seeing, the response was ulcerative wounds, circulatory wounds, diabetic wounds — wounds common in nursing homes. This comes as no surprise, given the majority of his clientele resides in an urban assisted-living facility.

Each generation faces a unique set of risks and nonrisks. Babies are at risk for sudden infant death syndrome. Unvaccinated kids are at risk for (aptly named) childhood diseases. Obviously, no one is supplying condoms to seniors, although I know of a few instances where they might have been offered if only to prevent the spread of disease. (Hey! One never knows with whom that lecherous 80-year-old canoodled before he was admitted.)

However, a distinction needs to be made. Yes, elderly residents of assisted-living or skilled nursing or independent-living communities are at acknowledged higher risk for certain types of wounds. That is a proven and acceptable reality. But their age and other factors are not an excuse for less-than-enthusiastic treatment and preventive measures. Just as it makes sense that a basically continent person of any age should not wear diapers for convenience, neither should it be assumed a pressure ulcer is inevitable. Despite the fact that clinicians like my cousin are prepared to provide excellent treatment, prevention should always be Priority One.

A niche within a niche

I recently attended the 2013 National Pressure Ulcer Advisory Panel (NPUAP) conference in Houston. My kudos to the Planning Committee for the lovely venue and accoutrements and some deliciously intriguing sessions. The focus of the conference was “Deep Tissue Injury: State of the Science.” I was most fascinated by presentations by Dr. Amit Gefen, and his Deep Tissue Injury from a Bioengineering Point of View Dr. Gefen an engineer who, among his other accomplishments (for one thing, he has published several times in OWM), creates skin tissue to test the effects of pressure and shear. Obviously, some may say that equating the results of testing laboratory-manufactured skin to human buttocks is akin to flying by the seat of your pants (pun intended) — that it is too abstract and too exclusive of other factors involved in deep tissue injury.

But as an observer of wound care literature for the past dozen years, I appreciate the effort to identify and isolate factors in a niche where everything seems connected to something. A wound is not necessarily just a wound per its etiology. And patient comorbidities. And location. And so on. This “niche” encompasses almost every aspect of healthcare. So drilling down — for study, for education, to provide care — ie, to create a niche within a niche— holds great promise and expands, as opposed to narrows — care possibilities.

You go, Dr. Gefen!

Barbara Zeiger, Editor
Ostomy Wound Management