November 26, 2017 in Education

January 21, 2016

Hyperbaric oxygen therapy (HBOT) doesn’t benefit diabetes patients suffering from severe foot ulcers, according to new research.

Since HBOT is already used in treating diabetic foot ulcers, researchers wanted to test whether HBOT could reduce the need for major amputation or aid in the healing of severe diabetic foot ulcers.

To conduct their study, researchers followed 103 of their diabetic patients with foot lesions at Wagner grade 2 to 4 over a period of 3 months.

The patients were randomly separated into 2 groups: the first group received 90 minutes of HBOT (oxygen at 244 kPa) and the other group received 90 minutes of placebo (oxygen at 125 kPa) for 30 days.

After follow-up, 22% of patients in the placebo group and 20% in the HBOT group were healed. However, another 25% in the placebo group needed a major amputation below the knee and 22% in the HBOT group needed an amputation.

“HBOT does not offer an additional advantage to comprehensive wound care in reducing the indication for amputation or facilitating wound healing in patients with chronic diabetic foot ulcers,” researchers concluded.

–Amanda Balbi


Fedorko L, Bowen JM, Jones W, et al. Hyperbaric oxygen therapy does not reduce indications for amputation in patients with diabetes with nonhealing ulcers of the lower limb: A prospective, double-blind, randomized controlled clinical trial. Diabetes Care. Published online before print January 6, 2016. doi:10.2337/dc15-2001.

Understanding the Braden Scale: Focus on Nutrition (Part 3)

November 24, 2017 in Education
Blog Category:

By Holly Hovan MSN, APRN, CWOCN-AP

Part 3 in a series analyzing the use of the Braden Scale for Predicting Pressure Sore Risk® in the long-term care setting. For Part 1, click here. For Part 2, click here.

A common misconception by nurses is sometimes predicting nutritional status based on a resident’s weight. Weight is not always a good predictor of nutritional status. Nutritional status is determined by many factors and by looking at the big picture.

Overview of Nutrition in Wound Care

What is nutrition? Nutrition or nutritional status is the process by which our body obtains food, vitamins, and minerals for proper growth and healing. Nutrition is also needed to maintain health and overall function. Good nutrition is needed for strong bones, teeth, and skin. Poor nutrition or dehydration can put someone at risk for pressure injuries, skin tears, and multiple other issues.

As per the Braden Scale, nutrition can be obtained in several ways, orally (PO), intravenously (IV), or by total parenteral nutrition (TPN). Also, a resident may be allowed nothing by mouth (NPO) because of an upcoming test or procedure, for bowel rest, or if the condition is unstable or doesn’t permit oral intake at the present time (e.g., intubated, sedated).

Braden Scale: Categories of Nutritional Status

The categories of the Braden Scale pertaining to nutrition can be seen below, but similar to the other categories, residents receive a score from 1 to 4, with 1 being very poor and 4 being excellent. It is important to read the definition of the subcategories and gain an understanding of what each subcategory is really saying. Some important points are:

  • If a resident is NPO, or is maintained on clear liquids or IV fluids (IVF) for >5 days = very poor nutrition
  • If a resident is intermittently refusing tube feeding (TF) or eats only about one half of each meal = probably inadequate nutrition
  • If a resident eats most of their meals and/or refuses meals but takes a supplement in place of a meal, or is on regular TF or TPN = adequate nutrition
  • For residents to have excellent nutrition, they would be snacking in between meals, never refuse a meal, and not be on a nutritional supplement.

When looking at nutrition, it is also important to take into account laboratory values, specifically albumin and pre-albumin. Additionally, it is important to look at C-reactive protein because if it is elevated, pre-albumin can be falsely low. Looking at weight trends and fluid fluctuations is also important; is the resident on a diuretic? Is the resident weighed consistently on the same scale? At the same time of day? Is the resident eating more? Less? These are all important questions to explore when completing an accurate Braden scale.

After examining the big picture and determining that the resident is at risk for poor nutrition, how can we fix this? When completing a Braden Scale, it is important not only to assign a score accurately to each category, but also to look at what interventions should be put into place based on that score. Some things to start with are to determine whether the resident is having a true weight loss or decline. if it is determined that, yes, the resident is losing a significant amount of weight or slowly declining over time, interventions are needed.

  • Does the resident have a favorite food? If so, maybe family members can bring it in.
  • Consider an evaluation or follow-up with the registered dietitian who can best determine the need for supplements and specific types.
  • Determine the cause of their poor appetite:
    • Does the resident dislike the food?
    • Is the resident undergoing chemotherapy or radiation?
    • Would an appetite stimulant or discussion with the provider be appropriate?
    • Difficulties chewing or swallowing?
    • Ill-fitting dentures?
  • If the resident is receiving TF, is it causing diarrhea? High residuals? Not well tolerated overall? Other issues with administration of TF?
  • Is there a decline in condition overall and/or is the resident approaching end of life? Would a goals of care discussion be appropriate, or a hospice or palliative care consultation?

Although nutrition is just one small part of the Braden Scale, it plays a huge role in the resident’s overall health status, ability to heal wounds, and likelihood of acquiring a hospital-acquired pressure injury. It is important to assess and reassess nutritional needs accurately and frequently via the Braden scale and with follow-up and recommendations from a registered dietitian. Early intervention and frequent follow-up on nutritional issues and concerns can definitely lead to more positive outcomes nutritionally and contribute to prevention of pressure injuries.

Note: For anyone who wishes to utilize the Braden Scale in their health care facility, you must request permission to do so. Please visit and complete the Permission Request form.

About the Author
Holly Hovan is a WOC nurse at the Cleveland Veterans Affairs Medical Center in long-term care/geriatrics. She has been practicing as a WOC nurse since 2013. Ms. Hovan has a passion for education, our veteran population, and empowering others to learn and succeed.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.


Tissue Oxygenation and Negative-Pressure Wound Therapy When Applied to the Feet of Persons With Diabetes Mellitus: An Observational Study

November 21, 2017 in Education

Lee, Ye-Na; Lee, Jong Seok; Han, Seung-Kyu; Jung, Hye-Kyung

Journal of Wound, Ostomy & Continence Nursing: November/December 2017 – Volume 44 – Issue 6 – p 517–523
doi: 10.1097/WON.0000000000000378
Wound Care

PURPOSE: Our group has reported that negative-pressure wound therapy (NPWT) decreases tissue oxygenation by 84% in the foot of diabetic patients because the pad of the connecting drainage tube and foam sponge of the NPWT system compress the wound bed. The purpose of this study was to determine whether an NPWT modified dressing application reduces tissue oxygenation in the feet of persons with diabetes mellitus.

DESIGN: A prospective, clinical, observational study.

SUBJECTS AND SETTING: We enrolled 30 patients with diabetic mellitus; their mean age was 63.9 ± 11.2 years (mean ± standard deviation). All were cared for at the diabetic wound center at an academic tertiary medical center in South Korea between 2014 and January 2015.

METHODS: Transcutaneous partial oxygen pressures (TcpO2) were measured to determine tissue oxygenation levels beneath modified NPWT dressings. A TcpO2 sensor was fixed at the tarsometatarsal area of the contralateral unwounded foot. A negative pressure of −125 mm Hg was applied until TcpO2 reached a plateau state; values were measured before, during, and after the modified NPWT. The Wilcoxon’ and Mann-Whitney Utests were used to compare differences between these measurements.

RESULTS: TcpO2 levels decreased by 26% during the modified NPWT. Mean TcpO2 values before, during, and after turning off the therapy were 54.3 ± 15.3 mm Hg, 41.6 ± 16.3 mm Hg, and 53.3 ± 15.6 mm Hg (P < .05), respectively.

CONCLUSION: Applying NPWT without the pad of the connecting drainage tube significantly reduces the amount of tissue oxygenation loss beneath foam dressings on the skin of the foot dorsum in diabetic patients.