Malnutrition and pressure ulcers: nutritional assessment tools

Incidence of pressure ulcers in intensive care unit patients at risk according to the Waterlow scale and factors influencing the development of pressure ulcers

AIMS

To determine incidence of pressure ulcers in patients at risk according to the Waterlow scale in intensive care units and to evaluate the effects of risk factors in critically ill patients.

BACKGROUND

Pressure ulcers continue to be an important health problem that increases the risk of illness and death, extends patients' length of hospital stay and increases healthcare expenses.

DESIGN

The study was conducted as a descriptive and prospective study.

METHOD

The sample consisted of 140 patients. Data were collected using a data collection form, the skin assessment instrument and the Waterlow scale.

RESULTS

The incidence of pressure ulcers in intensive care unit patients was found to be 14.3%. The majority of pressure ulcers (74%) were grade I. The mean length of time for pressure ulcer development was found to be 10.4 (SD 1.85) days. A statistically significant difference was found in the patients for pressure ulcer development according to their level of consciousness, activity, cooperation, length of stay, Waterlow scale score and C-reactive protein level. In the multiple stepwise logistic regression analysis, the most influential factors for pressure ulcer development were determined to be length of stay and activity level.

CONCLUSIONS

Extra care needs to be taken to prevent pressure ulcer development in intensive care unit patients who have an extended length of stay, are dependent for activities, have high Waterlow scores, are unconscious and are not cooperative.

RELEVANCE TO CLINICAL PRACTICE

This study determined the incidence of and factors that can affect the development of pressure ulcers in intensive care unit patients who are in a high risk group for the development of pressure ulcers and presented the importance of having Turkish nurses implement interventions directed at these factors.

Is obesity a risk factor for deep tissue injury in patients with spinal cord injury?

Deep tissue injury (DTI) is a severe form of pressure ulcers that occur in subcutaneous tissue under intact skin by the prolonged compression of soft tissues overlying bony prominences. Pressure ulcers and DTI in particular are common in patients with impaired motosensory capacities, such as those with a spinal cord injury (SCI). Obesity is also common among subjects with SCI, yet there are contradicting indications regarding its potential influence as a risk factor for DTI in conditions where these patients sit in a wheelchair without changing posture for prolonged times. It has been argued that high body mass may lead to a greater risk for DTI due to increase in compressive forces from the bones on overlying deep soft tissues, whereas conversely, it has been argued that the extra body fat associated with obesity may reduce the risk by providing enhanced subcutaneous cushioning that redistributes high interface pressures. No biomechanical evaluation of this situation has been reported to date. In order to elucidate whether obesity can be considered a risk factor for DTI, we developed computational finite element (FE) models of the seated buttocks with 4 degrees of obesity, quantified by body mass index (BMI) values of 25.5, 30, 35 and 40kg/m(2). We found that peak principal strains, strain energy densities (SED) and von Mises stresses in internal soft tissues (muscle, fat) overlying the ischial tuberosities (ITs) all increased with BMI. With a rise in BMI from 25.5 to 40kg/m(2), values of these parameters increased 1.5 times on average. Moreover, the FE simulations indicated that the bodyweight load transferred through the ITs has a greater effect in increasing internal tissue strains/stresses than the counteracting effect of thickening of the adipose layer which is concurrently associated with obesity. We saw that inducing some muscle atrophy (30% reduction in muscle volume, applied to the BMI=40kg/m(2) model) which is also characteristic of chronic SCI resulted in further substantial increase in all biomechanical measures reflecting geometrical distortion of muscle tissue, that is, SED, tensile stress, shear stress and von Mises stress. This result highlights that obesity and muscle atrophy, which are both typical of the chronic phase of SCI, contribute together to the state of elevated tissue loads, which consequently increases the likelihood of DTI in this population.

Malnutrition as a risk factor for the development of pressure ulcers

Malnutrition - as a fundamental aspect both in genesis as in healing of pressure ulcers - is the object of this update paper. Countless studies point out that malnutrition, immune function alterations, hypoalbuminemia, low hemoglobin levels, as well as low diet intake, as responsible for an increase in the risk of developing these lesions. Therefore, it is essential to include the assessment of the nutrition status - monitoring of the calorie-protein intake and the difficulties to use the nutrients - in the prevention and treatment protocols of this type of chronic wound.

Nutrition and wound healing: the necessity of assessment

Wound healing is an intricate affair and good nutritional status is essential to promote effective growth and repair of body tissue. Nutrients play vital roles in the constitution of a well-balanced diet and any depletion in a person's nutritional intake, especially proteins, can lead to malnutrition and protein-energy malnutrition, conditions which are known to have considerable impact on health and well-being and on the wound healing process. A holistic nutritional assessment is paramount to the early detection of nutritional deficiency and the use of recognized nutritional assessment tools can significantly increase practitioners' awareness in its undertaking. While nurses are renowned to have a central role in the management of the patient who, nutritionally are at risk, it is equally important to remember that overall management is essentially a multidisciplinary task.

Nutritional screening and assessment in cancer-associated malnutrition

Up to 85% of all patients with cancer develop clinical malnutrition, which negatively affects patients' response to therapy, increases the incidence of treatment-related side effects and can decrease survival. Early identification of patients who are malnourished or at risk of malnutrition can promote recovery and improve prognosis. In addition, early nutritional intervention is cost effective, as it reduces complication rates and length of hospital stay. The development and use of screening and assessment tools is essential for effective nutritional intervention and management of patients with cancer. Nutritional screening aims to identify patients who are malnourished or at significant risk of malnutrition. Patients identified through screening require referral to a dietician or specialist in nutrition for an in-depth nutritional assessment, involving examination of medical, dietary, psychological and social history, physical examination, anthropometry and biochemical testing. Interventions initiated after nutritional assessment should be tailored to the individual and take into consideration the patient's prognosis. Nutritional care is a fundamental aspect of nursing practice and nurses are ideally placed to play an essential role in the early detection and screening of malnutrition in patients with cancer.

Pain relief and wound care in a young woman with special needs

This article focuses on a teenage girl with cerebral palsy admitted for an orthopaedic procedure, and highlights the problems of pain and wound management discussed in this journal's Challenges in Wound Care study days.