Elsevier

Nutrition

Volume 30, Issues 7–8, July–August 2014, Pages 841-846
Nutrition

Applied nutritional investigation
Nutritional intakes of patients at risk of pressure ulcers in the clinical setting

https://doi.org/10.1016/j.nut.2013.11.019Get rights and content

Abstract

Objective

Malnutrition is a risk factor for pressure ulcers. The aim of this study was to describe the energy and protein intakes of hospitalized patients at risk for pressure ulcers and to identify predictors of eating inadequately.

Methods

An observational study was conducted in four wards at two hospitals in Queensland, Australia. Adult patients with restricted mobility were observed for 24 h, and information such as oral intake and observed nutritional practices was collected. A chart audit gathered other demographic characteristics, clinical, anthropometric, and dietary information. t Tests or one-way analysis of variances were used to identify differences in total energy and protein intakes. Univariate and multivariate regression analyses were conducted to determine predictors of eating inadequately (i.e., intake of <75% of estimated energy and protein requirements).

Results

Mean energy and protein intakes of the 184 patients were 5917 ± 2956 kJ and 54 ± 28 g, respectively. Estimated energy and protein requirements were calculated for 93 patients. Only 45% (n = 42) and 53% (n = 49) met ≥75% of estimated energy and protein requirements, respectively. In multivariate analysis, patients on the renal ward were 4.1 and 4.6 times more likely to be eating inadequately for energy and protein, respectively (P < 0.05). Patients who consumed any amount of oral nutrition support were 5.1 and 15.5 times more likely be eating adequately for energy and protein, respectively (P < 0.05).

Conclusions

Renal patients are more likely to be eating inadequately, although any consumption of oral nutrition support seems to increase likelihood of eating adequately.

Introduction

Malnutrition is a common and costly problem in the hospital setting, affecting as many as 20% to 50% of patients [1], [2]. Its consequences are severe and include impaired immunity, delayed recovery and healing, loss of muscle mass and function, and poorer quality of life [3]. Malnutrition increases hospital length of stay (LOS) and hospital costs among various groups of patients [4], [5], [6], and is also directly associated with the development and severity of pressure ulcers (PUs) [7], [8].

PUs place a large burden on both the patient and the health care system. The prevalence of PUs ranges from around 5% to 30% of all hospitalized patients [7], [9]. For the patient, PUs result in numerous medical complications, including increased risks for infection and mortality, and lengthy healing times [3], [10]. Other problems arising from PUs include pain, discomfort, decreased mobility and independence, wound exudates and odor, and social isolation [11], [12]. PUs result in severe consequences to the health care system, including increased hospital costs and LOS [13], [14].

Malnutrition has been associated with at least twice the odds ratio of having a PU [7]. Mechanisms by which malnutrition increases PU risk may be related to body composition, skin and tissue integrity, and mobility [3], [11], [15]. Low body weight may be associated with PU as a result of an increase in bony prominences and less fat tissue to distribute pressure [11]. Malnutrition also may result in impaired skin integrity and resistance to pressure owing to decreased nutrient availability for tissue maintenance and repair [3]. Furthermore, malnutrition is associated with decreased mobility, which is an independent risk factor for PUs [3], [15].

Oral or enteral nutritional supplementation in groups of older patients deemed at risk for PUs may contribute to PU prevention [16]. Although most studies have failed to reach statistical significance individually, likely because of small sample sizes, a meta-analysis found that the provision of oral or enteral nutrition support resulted in a 26% lower incidence of PUs in high-risk patients compared with routine care [16].

To our knowledge, no hospitals in Australia routinely prescribe oral nutrition support (ONS) to at-risk patients for the prevention of PUs. Given this, understanding the oral intake of patients at risk for PUs and factors determining oral intake in routine care is important if we are to ensure those at risk for PUs are eating adequately. Although investigations of dietary intakes of hospitalized patients have been conducted [17], [18], [19], [20], to our knowledge, no studies have described nutritional intakes among a group of patients at risk for PUs. Therefore, it is unknown whether the current knowledge about the intakes of hospital patients in general can be applied to patients at risk for PUs. The aim of this study was to describe the nutritional intakes of hospitalized patients at risk for PUs, and predictors of inadequate energy and protein intakes.

Section snippets

Study overview

A multisite, observational study was undertaken, consisting of two components: 24-h observations and chart audits. Ethical approval was gained through Queensland Health (reference no. HREC/11/QTHS/111) and Griffith University (reference no. NRS/40/11/HREC).

Setting

Data collection was conducted in four medical wards (renal, immunology, respiratory medicine, and general medicine) at two public metropolitan hospitals in Southeast Queensland, Australia. A randomized data collection schedule was used to

Results

A total of 241 patients were recruited and participated in the study; however, complete data was available for only 184 patients. Patient characteristics for these 184 patients are summarized in Table 1. There were significant differences between sites regarding LOS and serum albumin. The most common diagnoses were infection (22.3%), respiratory disease (16.3%), and gastrointestinal disease or condition (6.5%). The most common comorbidities were hypertension (48.9%), chronic obstructive

Discussion

This study directly observed the oral intakes of hospital patients in an attempt to understand factors associated with improving dietary intake in patients at risk for PUs. Predictors of eating inadequately (i.e., intake of <75% EER and EPR) were being on the renal ward, and the absence of any intake of ONS.

Mean energy and protein intakes in this study are comparable to previous studies describing the intakes of general hospitalized patients [17], [19], [20], [32]. Many patients at risk for PUs

Conclusion

Many hospitalized patients at risk for PUs have insufficient oral intakes to meet their requirements. Predictors of eating inadequately were being on the renal ward and lack of ONS intake. Nutritional interventions targeting PU prevention should focus on ONS and consider other factors that may influence oral intake.

Acknowledgments

The authors acknowledge Sharon Latimer for her role in data collection. This research received funding from the Area of Strategic Investment Health and Chronic Diseases, Griffith University.

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SR was responsible for the conception and design of the study; collection, assembly, analysis, and interpretation of data; drafting and revision of manuscript; and approval of final version of manuscript. WC and BD were responsible for conception and design of the study; analysis and interpretation of data; drafting and revision of manuscript; and approval of the final version of the manuscript. ML and MB were responsible for interpretation of the data; drafting and revision of the manuscript; and approval of the final version of the manuscript.

The authors declare no conflict of interest.

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