Presentation on theme: "Presented by: Vivian Cheng, Dietetic Intern 17 July 2008"— Presentation transcript:
1 Presented by: Vivian Cheng, Dietetic Intern 17 July 2008 Are clinical dietitians appropriately consulted and what nutritional interventions are implemented for patients identified at risk for skin breakdown with a nutritional deficit at QCH?Presented by:Vivian Cheng, Dietetic Intern17 July 2008
2 Agenda Prevalence of pressure ulcers Pressure ulcer risk factors Pressure ulcer stage classificationBraden scaleNutrition and wound healingStudy ResultsRelevance to Practice
3 Prevalence of Pressure Ulcers A major health problemFinancial burden to healthcare systemCanadian Association of Wound Care estimates:25% Acute care30% Non-acute care15% Community careQCH Pressure Ulcer Prevalence Study17% Point prevalence all stages (2007)20% Point prevalence all stages (2006)19% Point prevalence all stages (2005)
4 Pressure UlcersLocalized injury to the skin and/or underlying tissue usually over a bony prominenceRisk factorsPressureShearFrictionMoistureHost FactorsMobilityIncontinenceNutritional StatusSkin PerfusionsNeurological Diseases
5 Cost of Treatment Cost to heal one ulcer: Anuual cost: $5000-$25,000 USDAnuual cost:over $5 billion USDBennet et al., 2004
6 Pressure Ulcer Staging System Blancheable Erythema (BE)Stage IStage IIStage IIIStage IVStage X
7 Blancheable ErythemaA reddened area of unbroken skin over a bony prominence.
8 Stage I Ulcer Non-Blanchable Erythema A red discoloration of unbroken skin over a bony prominenceNPUAP, 2008
9 Stage II Ulcer Stage II Ulcer Partial thickness skin loss involving the epidermis and/or dermisNPUAP, 2008
10 Stage III Ulcer Stage III Ulcer Full thickness skin loss over a boney prominence, involving damage of the subcutaneous tissueNPUAP, 2008
11 Stage IV Ulcer Stage IV Ulcer Full thickness skin breakdown involving complete loss of the epidermis, dermis, subcutaneous tissue and possibly extending into muscle, bone and joint.NPUAP, 2008
12 Stage X Ulcer Stage X Ulcer Cannot be accurately stage due to the presence of necrotic tissue covering the wound baseNPUAP, 2008
14 Nutrition and Wound Healing Nutrition to promote optimal wound healingPositive nitrogen balanceAdequate total caloriesNutrition risk indicatorsLow albumin (<3.5 mg/dL)Low body weight (<85% ideal body wt)5-10% significant wt loss over one monthLow serum transferrin (<170 mg/dL)
15 Nutrition Status & Wound Healing Malnourished IndividualWell-Nourished IndividualAdapted from Furguson et al., 2000
16 Study Aims & Objectives Determine whether dietitians are being appropriately referred for consultation to provide nutritional care for patients at risk for skin breakdown with a nutritional deficit as identified by the Braden Scale.Describe the nutritional interventions currently implemented for patients at risk for skin breakdown with a nutritional deficit.
17 Study Methods Data Collection: Nov to Dec 2007 Cluster Sampling Patient medical chartsCluster SamplingInclusion criteriaDocumented Braden Score<18 – indicative for pressure ulcerationNutritional Deficit2 or less on the nutrition subscale
18 Variables Explored Presence/ reason for dietitian consultation Nutritional interventionAge, room locationUlcer site/ stageLab dataSerum protein albuminTotal lymphocyte count
19 Study results and Discussion 147 charts reviewed42 (28.6%) met the inclusion criteria15 males27 femalesMean age: 78Mean documented Braden score: 14.6 (indicative of pressure ulceration)
20 42 Met Inclusion Criteria 147 Charts Reviewed42 Met Inclusion CriteriaDietitian ConsultPressure Ulcer101110Poor intake x9Skin breakdown x5Diet teaching x2Nutrition support x1Other x4Stage I x10Stage II x3Stage III x5Stage IV x0Undefined x311
21 Were RD appropriately referred? Dietitian ConsultPressure Ulcer101110Poor intake x9Skin breakdown x5Diet teaching x2Nutrition support x1Other x411Only half of the identified high risk patients in this study were appropriately referred to the dietitian for nutrition care.
22 Nutritional Interventions Stage I Ulcers Incidence of treatmentIncidence rate of treatmentNutrition assessment2100%Energy 30 kcal/kgPRO 1.2g / kgFluid mL/kgCannot be determinedN/AMultivitamin
23 Nutritional Interventions Stage II Ulcers Incidence of treatmentIncidence rate of treatmentNutrition assessment2100%Energy kcal/kgPRO 1.2g / kg150%Fluid mL/kgCannot be determinedN/AMultivitamin
24 Nutritional Interventions Stage III Ulcers Incidence of treatmentNutrition assessment4100%Energy kcal/kg375%PRO g / kgFluid mL/kgCannot be determinedN/AMultivitamin2Vitamin C mg/d50%Elemental Zinc mg/d
25 Nutritional Interventions Undefined-Stage Ulcers Incidence of treatmentNutrition assessment3100%Energy kcal/kg266.7%PRO g / kg133.3%Fluid mL/kgCannot be determinedN/AMultivitaminVitamin C mg/dElemental Zinc mg/d
26 What nutritional wound care interventions are implemented? Dietitian ConsultPressure Ulcer101110Poor intake x9Skin breakdown x5Diet teaching x2Nutrition support x1Other x4Stage I x10Stage II x3Stage III x5Stage IV x0Undefined x311Nutritional would care interventions as usually provided as recommended by the literature and practice guidelines when dietitians were involved
27 Study Conclusions Half were appropriately referred Pt most often received nutritional intervention when dietitians involvedConsequently, high risk patients not receiving appropriate nutritional careDevelopment of pressure ulcersDelayed wound healing
28 Study Limitations Data not always complete Small Sample Size Variables exploredUndocumented Braden scoreSmall Sample SizePressure ulcers with undefined stage
29 Relevance to PracticeNutrition is an important factor to promote wound healingDietitians are key players in multidisciplinary teamMore effective referral systemAnticipated changes in Wound and Skin Care PolicyAcknowledge the importance of nutrition in wound healing processdocument nutrition risk indicators
30 ReferencesCanadian Association of Wound Care [Internet]. [Toronto, ON]: Pressure ulcer awareness: prevent pressure ulcers. [cited 2008 June 14]. Available from:National Pressure Ulcer Advisory Panel [Internet]. [Toronto, ON]: Updated Staging System. [cited July 3]. Available from:Bennett G, Dealy C, Posnett J. The cost of pressure ulcers in the UK. Age and Ageing (3):
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