EUROPEAN PRESSURE ULCER ADVISORY PANEL

Nutrition Practice in the Preventing/Treating of Pressure Ulcers – Taiwan Experience
Shyh-Dye Lee, MD, MPH
Taiwan

General Information
Taiwan is a special country in the world, whatever its political-economic status and the well-developed high technology in the category of electronics and computerizing. However, it is sparsely mentioned or referred to in its long-term care system. Lots of problems call attention from the publicity to the long-term care delivery in Taiwan. ‘Pressure ulcer’ is usually a common one of them, it can be observed in the hospitals, facilities, others institutions and even in the community settings. In general, nutrition has not deserved its key status in the health care system under medical care-centered environment. But, as an important component, nutrition always plays a key role in itself, in preventing or treating pressure ulcers.

What Practice is Taking Place for Pressure Ulcers in Taiwan

1. Screening, Assessment and Planning Intervention
There are more than 80,000 elderly being supposed to take the service delivery of long-term care. Among them, 22–26% are cared for in institutions, and the remainder stay in their communities. All patients or residents showing the potential or risk of developing pressure ulcers are mandatory to be screened or assessed early. Especially those with impaired ability – such as bed- or chair-bound individuals – should be assessed for additional factors that increase risk for developing pressure ulcers. But it is not always performed well.

Assessing the status/conditions of the risk for pressure ulcers might pose the needs on the care foci such as nutrition, hydration, circulation, pressure reduction, skin care, supporting, underlying medical care and even the patient/caregiver education. Based on risk factors schema, the victims or possible victims of pressure ulcer are supposed to be evaluated with the tool of Braden Scale.

General health function level and nutrition indicators, such as total calories, protein (plasma protein, serum albumin and transferrin …), cholesterol, vitamin, and zinc level, are the main parts to pay attention to during care practice on the victims or possible victims of pressure ulcers.

In Taiwan, owing to the reluctance of measuring the accurate length/height of the impaired ones, Harris-Benedict Equation is usually adopted regularly for the evaluation of the nutrition needs of care receivers, applied by the dieticians or nutrition professional personnel during their practice of care. Recently, knee-height caliberization was begun as an alternative way to approach the nutrition needs.

2. Specific Intervention for Pressure Ulcers
Just as in most parts in the world, specific intervention is settled according the stage of the pressure ulcer. In Stage I, the tactics of intervention is prevention, i.e. applying pressure reduction techniques along with application of transparent adhesive films or hydrocolloid dressings to protect ‘reddened’ areas of skin at risk for breakdown. In Stage II, it is cleansing/protection; and in Stage III and IV, disinfection, debridement, absorption and protection are taken. Certainly, some but not much complementary therapy exist, such as home health application, patient/caregiver education and alternative medication approaches in preventing or treating pressure ulcers.

3. Education/Training for the Care Personnel
Related education/training program is frequently carried out during policy making. Mostly, the issues of pressure ulcers are incorporated into the theme of wound care in the nursing training programs. Annual continuous education course is composed of a package design, with 22 topic-hours (i.e. 14 hours for lectures and 8 hours for practice)

4. Home Care Application
Home care is the main stream of the long-term care. The patient and main caregiver will, of necessity, have a very active role in the pressure ulcer care under home setting because the home health nurses’ exposure to the wound care will be only periodically or sporadically. Ideally, the frequency of planned visits is based on the patient/caregiver education needs as well as the condition of the pressure ulcer, and visits can be increased or decreased as deemed necessary by the home health nurse.

5. Patient/Caregiver Education
Although home health nurses should perform dressing changes by using sterile technique, it is more practical to instruct the patient/caregiver to apply clean technique. As for the main themes of patient education, it does always include pressure ulcer assessment, skin care, dressing changes and related procedural care, medications (purpose, action, dosage, side effects and administration), infection control pressure reduction/relief (device use, operating, and maintenance), and lifestyle that influence pressure ulcer healing and skin breakdown and preventative interventions.

6. Alternative Medication Approach
In Taiwan, even in Oriental regions, alternative medication, especially in the isolated or rural areas, takes its root in the mind of the population. Pressure ulcers couldn’t be exemplified. In addition to care by western medication, some herb medications might be tried P.O. and topically in the mean time occasionally.

Perspective of Tasks on Pressure Ulcer
There are lots of components and determinants in the long-term care system, including, at least, need/demand estimation, resources providing, financial & economic support, organizing, planning, administration, policy, and service delivery, etc. Now, here today, the theme of pressure ulcer is just an important part of it. So far, there is still no fundamental epidemiological data about ‘Pressure Ulcers’ to be presented, the incoming tasks are to survey these problems, to set up the framework of ‘Pressure Ulcer Care’ and to construct the delivery model in the long-term care system.

References

1. Aliman RM: Epidemiology of pressure sores in different population. Decubitus l989; 2: 30–3.
2. Agency for Health Care Policy and Research: Pressure Ulcers in Adults, Prediction and Prevention. Washington DC, U.S. Department of Health, Human Services, 1992.
3. Breslow RA, Hallfrisch J, Guy DG, et al: The importance of dietary protein in healing pressure ulcers. J Am Geriatr Soc 1993; 41: 357­–62.
4. Breslow RA and Bergstrom N: Nutritional prediction of pressure ulcers. J Am Diet Assoc 1994; 94: 1301–4.
5. Cambell SM, Gallagher-Alired C: Pressure Ulcer Prevention and Intervention, A Role for Nutrition. Ohio: Ross Lab. June, 1995.
6. Tsan LC: Pressure ulcer and its nutrition care, Bulletin of Intravenous and Enteral Nutrition, 1999; 12–5 (in Chinese).

Wound assessment is pivotal to the development of the plan of care and evaluation of healing. This session will focus on assessment of wounds and measurement of healing. Healing by primary and secondary intention will be addressed. Strategies to evaluate healing will be compared. Principles of documentation will be discussed.

Objectives
Upon completion of this presentation, the participant will be able to:

• Assess wounds healing by primary and secondary intention.
• Compare and contrast several approaches to evaluate healing.
• Propose critical dimensions of documenting wound assessment and healing.

Content Outline
Assess wounds healing by primary and secondary intention
Assessment of healing by primary intention

• Approximation of wound edges.
• Inflammation
• Drainage
• Healing ridge

Assessment of healing by secondary intention

• Location
• Size
• Tissue type: Granulation, slough, necrotic,
• Epithelial edge
• Exudate
• Undermining/tunneling
• Stage if pressure ulcer

Assessment items that do not tell you directly about the wound

• Erythema of surround tissue
• Breaks in surrounding tissue
• Edema
• Rashes

Must assess the wound in relation to the underlying cause

• Surgical wound: reason for surgery, surgical course
• Vascular disease: arterial vs. venous
• Diabetic ulcer: neuropathy; glucose/A1C level.
• Pressure ulcer: Immobility, inactivity, incontinence, LOC, nutrition

May use a validated instrument such as the Pressure Sore Status Tool (PSST).

Compare and contrast several approaches to evaluate healing.
Healing is restoration of structural and functional integrity.

Requires

• Assessment of the wound
• Evaluation of healing based on pre-set criteria

Available Ways to Evaluate Healing

• Routine examine
• Use of validated instrument:
  – Staging
  – Sessing Tool
  – Sussman Tool
  – PSST
  – PUSH Tool

Propose critical dimensions of documenting wound assessment and healing.
Documentation Principles

• Know the protocol for your facility
• Document every dimension assessed [include diagrams and photographs]
• Do NOT make up findings if you forget to assess them
• Document what is not present as well as what is present
• Include all aspects of care in your documentation

Fit Between Healing and Principles of Care

• The goal of care for most wounds is healing – if you question it, clarify
• Wounds heal fastest in a moist environment – not a wet or a dry environment – provide it
• Dead tissue impairs healing – remove it
• Bacteria burden slows healing – remove it
• Pain slows healing & occurs not only when dressings are changed – treat it
• Vasoconstriction slows healing – mitigate it by providing adequate intravascular volume, reducing pain, reducing unnecessary noise, reducing cold, recognizing and helping the patient mitigate stress.

Selected Bibliography

• Bachand, P.M., McNichols, M.E. (1999). Creating a wound assessment record. Advances in Wound Care, 12(8): 426–429.
• Bates-Jensen, B. (1997). The Pressure Sore Status Tool a few thousand assessments later. Advances in Wound Care, 10(5): 65–73.
• Brown-Etris, M. (1995). Measuring healing in wounds. Advances in Wound Care, 8(4): 53–58.
• Ferrel, B.A. (1997). The Sessing Scale for measurement of pressure ulcer healing. Advances in Wound Care, 10(5): 78–90.
• Krasner, D. (1997). Wound healing scale, version 1.0: A proposal. Advances in Wound Care, 10(5): 82–85.
• Lazarus, G.S., Cooper, D.M., Knighton, D.F., et al., (1994). Definitions and guidelines for assessment of wounds and evaluation of healing. Archives of Dermatology, 130: 489–93.
• Sussman, C., Swanson, G. (1997). Utility of the Sussman Wound Healing Tool in predicting wound healing outcomes in physical therapy. Advances in Wound Care, 10(5): 74–77.
• Thomas, D. R., Rodeheaver, G.T., Bartolucci, A.A., et al., Pressure ulcer scale for healing: Derivation and validation of the PUSH tool. Advances in Wound Care, 10(5): 96–101.