Pressure ulcers in the elderly are a costly (both financially and physically) condition in the hospital setting. Evidence-based practice has resulted in nutrition becoming a key focus in regards to the treatment of pressure ulcers in the elderly. A study showed that the incremental cost per pressure ulcer was $2,731, and this cost increased to the rate of $59,000 if the pressure ulcer was associated with another co-morbidity like osteomyelitis (Livesley & Chow, 2012). Pressure ulcers are not a disease that takes weeks to accumulate, on the contrary, the onset of pressure ulcer development occurred within a median of nine days after a patient was admitted to the hospital (Livesley & Chow, 2012). This could mean that the lack of nutrition leading to the hospital stay, played a role in development of the pressure ulcer. With assisted living facilities, dietary management is usually done on a per-resident basis, giving each individual resident a preferred option that is nutritionally sound.
Malnutrition affects the skin, mucous membrane, and immune system. When inadequate nutrition is combined with other risk factors for pressure ulcer development, malnutrition increases the risk up to 74% (Beverlin, 2012). This is an alarming figure that shows how important nutrition is for proper wound healing. Elderly patients have a decrease in skin elasticity, and poorer blood circulation than that of younger adults. Elderly patients also have a greater chance of having more than one co-morbidity, which as a result, makes them more susceptible to pressure ulcers. Undernutrition and protein-energy malnutrition occurs in 23% to 85% of the elderly population (Beverlin, 2012). When the focus is on the elderly patient in the hospital setting, those numbers increase tremendously. Wound healing is a process that involves many factors including cells, tissue, and the immune system. Nutrients are needed for the healing process, as they are essential to every aspect of the human body. Pressure ulcers are associated with longer hospitalization, increased mortality, and lower quality of life for older adult patients (Beverlin, 2012). Studies have suggested that about 1 in 25 of hospitalizations relating to pressure ulcers as a primary diagnosis, end in death (Beverlin, 2012).
Reliability involves the consistency of a measurement method when conducting an experiment (Grove et al., 2015). Consistency is the key in determining the reliability of an experience, and reliability is usual measured by one or more methods. The Braden Scale, developed in 1983, is a widely used tool for identifying older adult patients who are at risk for developing pressure ulcers (Beverlin, 2012). The is a test-retest reliability measurement method because this test is repeated multiple times throughout the day, on a consistent basis, throughout the patient’s hospital stay.
Validity of an instrument is measured by how well an instrument reflects the concept being studied (Grove et al., 2015). The Bates-Jensen Wound Assessment Tool (BWAT) is a content validity measurement method that uses 13 items to describe a pressure ulcer. The BWAT describes the ulcer’s skin color, edges, exudate types, depth, peripheral tissue edema, and wound size amongst other things. When evaluating the Beverlin (2012) article, the usage of The BWAT and the Braden Scale are both measurement methods that help solidify the reliability and validity of the experiment. As most nurses know, the Braden Scale is the most reliable measurement tool when assessing pressure ulcer risks and development. The Beverlin (2012) article used a descriptive, quasi-experimental design study that included frequencies, chi-square tests, and t test. These items further validated the statistical information found in the study.
In the National Institute for Health and Care Excellence article found on the National Clinical Guidelines Centre, nutrition is highlighted as a key in preventing and healing pressure ulcers. The website lists a prerequisite for patients with pressure ulcers, that they receive a nutritional assessment by a dietitian or any other healthcare professional who holds the preferred competencies (NGC, 2014). It is important that the elderly patient, with the pressure ulcer, undergoes a dietary evaluation in order for the nutritional protocol to be tailored to the exact need of the patient. Nutritional supplementation should only be offered to patients who have a nutritional deficit (NGC, 2014). Patients who do not have a nutritional deficit would most likely not benefit from a nutritional comprehensive program. Most elderly patients are in a nutritional deficit because of their age, lack of interest in food, changes of taste buds, and change of metabolism, but it is always important to assess each elderly individual separately. Information should be provided to elderly patients, and their family on how to maintain a nutrient dense diet (NGC, 2014). Patients and family members should be educated on diet modifications, so when the patient is discharged, they are equipped with the knowledge to consume a more protein-energy based diet.
There are many risk factors for nutritional deficit related pressure ulcers including below optimal energy, protein intake, and dysphasia or chewing related problems (Posthauer, 2014). It is important to determine why the patient has subpar nutrition intake. As stated, a comprehensive nutritional plan, needs to be tailored to the needs of the patient. A patient could have a decline in nutrients because the patient needs more of a soft texture diet. As people get older, some adults find it difficult to chew foods, so their diet needs to be modified. Dehydration is also a risk factor for pressure ulcers (Posthauer, 2014). When malnutrition is assessed in patients, water or fluid intake is included in the assessment. Some elderly adults choke on thin liquids, so their fluids need a nectar or honey consistency. IV therapy is also implemented, if the patient is not receiving adequate fluid intake. For elderly patients, with pressure ulcers, who are not consuming enough nutrients, a multi-vitamin with minerals is included in their nutrition plan (Posthauer, 2014).
In conclusion, for the elderly patient population, the use of a comprehensive nutritional protocol reduces the future risk of pressure ulcers, charges to patients, and length of hospital stay compared with elderly patients receiving routine hospital care. The nutritional intervention discussed was effective in improving pressure ulcer wound healing, decreasing hospital stay, and showing a significant difference in charges between the two groups (Beverlin, 2012). Whether in the hospital setting, or in an assisted living facility, nutrition is important. That is why every assisted living facility should be partnered with a reputable dietician and diet plan for their residents.
References
Beverlin, A. (2012). Effects of a comprehensive nutritional program on pressure ulcer healing, length of hospital stay, and charges to patients. Clinical Nursing Research, 22(2), 186-205. doi: 10.1177/1054773812457673
Grove, S., Gray, J., & Burns, N. (2015). Understanding nursing research text w/ study guide package (6th ed). St. Louis: Elsevier.
Livesley, N., & Chow., A. (2012). Infected pressure ulcers in elderly individuals. Oxford Journals, 35(11), 1390-1396. Retrieved from http://cid.oxfordjournals.org/content/35/11/1390.full
National Clinical Guideline Centre. (2014, April). Pressure ulcers: prevention and management of pressure ulcers. National Institute for Health and Care Excellence, 37. Retrieved from https://www.guideline.gov/summaries/summary/48026/pressure-ulcers-prevention-and-management-of-pressure-ulcers#
Posthauer, M. (2014). Nutrition: fuel for pressure ulcer prevention and healing. Nursing 2014, 44(12), 67-69. doi: 10.1097/01.NURSE.0000456389.22724.ef