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The Braden Scale for Predicting Pressure Ulcer Risk, is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstrom. [1] The purpose of the scale is to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer .
Pressure ulcers can trigger other ailments, cause considerable suffering, and can be expensive to treat. Some complications include autonomic dysreflexia, bladder distension, bone infection, pyarthrosis, sepsis, amyloidosis, anemia, urethral fistula, gangrene and very rarely malignant transformation (Marjolin's ulcer – secondary carcinomas in chronic wounds).
A total Waterlow score ≥10 indicates risk for pressure ulcer. A high risk score is ≥15. A very high risk exists at scores ≥20. The reverse side of the Waterlow card lists examples of preventive aids and interventions. [2]
Targeted temperature management (TTM) previously known as therapeutic hypothermia or protective hypothermia is an active treatment that tries to achieve and maintain a specific body temperature in a person for a specific duration of time in an effort to improve health outcomes during recovery after a period of stopped blood flow to the brain. [1]
A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician ...
Diabetic foot ulcer is a breakdown of the skin and sometimes deeper tissues of the foot that leads to sore formation. It is thought to occur due to abnormal pressure or mechanical stress chronically applied to the foot, usually with concomitant predisposing conditions such as peripheral sensory neuropathy, peripheral motor neuropathy, autonomic neuropathy or peripheral arterial disease. [1]
Critical limb ischemia is diagnosed by the presence of ischemic rest pain, and an ulcers that will not heal or gangrene due to insufficient blood flow. [3] Insufficient blood flow may be confirmed by ankle-brachial index (ABI), ankle pressure, toe-brachial index (TBI), toe systolic pressure, transcutaneous oxygen measurement (TcpO2 ), or skin perfusion pressure (SPP).
The human body maintains a core body temperature at around 37 °C or 98.6 °F through mechanisms controlled by the thermoregulatory center within the hypothalamus.When the body is exposed to high ambient temperatures, intense physical exertion, or both, the thermoregulatory center will initiate several processes to dissipate more heat: [9] [11] [12]