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PICO Do patients 65+, in nursing homes, who have scored 18-15 on the Braden scale, show a decrease in prevalence of Pressure Ulcers by receiving a supplement of 30g of protein in their daily diet, compared to patients 65+, who do not receive the 30g of protein in their daily diet?

Literature Review •  Nutrition supplementation such as increased protein in conjunction

with vitamins and minerals such as zinc, arginine, vitamin A etc. may aid in the prevention of pressure ulcers in this specific population (Ishida, I., Kameda, T., Sanada, H., Sato, A., Taguchi, F., Takanao, K., Ueno, S., Watanabe, T., Yatable, J., & Yatabe, S.M., 2013).

•  Protein supplements should be offered in between meals to patients at risk of malnutrition in addition to regular meals to aid in prevention of pressure ulcers (Alderden et al, 2011).

•  Nutritional supplementation should be given to patients who are not receiving adequate amounts of nutrition (Avital, L., Jones, K., Marsden, G., Stansby, G., 2014).

•  Greater reduction in ulcer size was found when protein supplementation was used (Avital et al, 2014).

•  Other modalities must be taken in addition to protein supplementation. These included frequent repositioning, skin assessments and the use of pressure relieving devices (Alderden et al, 2011).

Major EBP recommendations

Evaluation

Methods of Implementation Goal: Decrease Pressure Ulcer prevalence by increasing protein intake. Clinical Setting: Long-Term care facility- Bethel Nursing and Rehabilitation Center. Sample Population: Patients included must be 65 and older with a score of 15-18 on the Braden Scale. Implementation: •  Resident will receive an extra 30g of protein in a smoothie

during lunch. The protein powder, Optimum Nutrition powder, will be mixed with fruit and other smoothie ingredients.

•  Nurses and CNAs will observe residents intake of the smoothie and record the data on a flow sheet.

•  Skin will be assessed according to the Braden Scale by a nurse trained in pressure ulcer and wound assessment three times a week for the development of pressure ulcers.

Adrian  Anderson,  Emily  Elisha,  Hannah  Hirsch,  Samantha  Stewart  Pace  University,  College  of  Health  Professions,  Lienhard  School  of  Nursing  

Evidence  Based  Prac/ce  Improvement:  The  Benefits  of  Protein  in  Pressure  Ulcer  Preven/on  

Pressure  Ulcer  points  

Background •  The development of pressure ulcers continues to be a problem

for older adults, age 65+ in the hospital, home and long-term care setting (Ayello, 2012).

•  Prevalence rates are estimated to be 11.9% in acute care, 29.3% in long term acute care, 11.8% in long term care, and 19% in rehabilitation centers”. The yearly incidence rate of all populations, for pressure ulcers is 6-7%. (Ayello, 2012).

•  Morbidity rate of 4.5% and mortality rate of 2.81%. (Curry et al, 2012).

•  An estimated national cost of 9.1-11.6 billion dollars, individual patient cost of $20,000- $151,000 per pressure ulcer (AHRQ, 2014).

   

Search Strategy •  Databases: CINAHL, PubMed, and the National Guideline

Clearinghouse. •  Search Terms: Pressure Ulcer, Nutrition, Prevention and

Braden Scale. •  Delimitations: Publication dates from 2010 to present, full

text only and English language only. Studies excluded were those including patients under age 65 and those negating the sole benefit of protein on wound prevention.

•  Additional Search Criteria: Studies involving patient’s ages 65+ in nursing homes with a Braden Scale grade of 15-18. Articles discussing the benefits of protein and nutritional supplementation on prevention and healing of pressure ulcers.  

•  Offer nutritional supplements to “at risk” patient (Atival, Jones, Marsden & Stansby, 2014).

•  Frequent turning of patient every 2 hours (Barrett, Bergstrom, Horn, Rapp, Stern & Watkiss, 2013).

•  Skin assessments and frequent skin checks (Alderden et al, 2011).

•  Nutritional assessments in conjunction with the Braden Scale (Ishida et al, 2013).

•  We will evaluate each residents score on the Braden Scale before

implementing protein supplementation. •  At the end of six weeks, each residents Braden Score will be re-

assessed, to determine if the level of risk for developing pressure ulcers has improved, stayed the same or deteriorated. Based on this assessment we will be able to determine whether protein supplementation is effective.

•  The statistical program that will be used for data analysis is the Statistical Package for the Social Sciences (SPSS). Data will be analyzed using T tests with p value of 0.05 to determine statistical significance.

Change Process •  Obtain consent from administrative and nursing directors to

implement intervention. •  Discuss with dieticians if 30g of protein is contraindicated for any

patient. •  Inform CNAs of the idea and request their assistance in encouraging

the residents to comply. •  Inform each resident of the benefits of protein smoothies in

prevention of PU. •  Serve smoothies every day during lunch. •  Perform weekly PU assessments on each resident. •  Assess if those at risk for developing PU, did not develop a PU after

six weeks.

References Level of Evidence: 1- Systematic Reviews, Meta- Analysis, EBP Guidelines Agency for Healthcare Research and Quality. (2014). Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. Retrieved from http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/index.html Level of Evidence: 4- Cohort Studies or Case Control Studies Alderden, J., Taylor, S. M., Whitney, J. D., & Zaratkiewicz, S. (2011). Risk profile characteristics associated with outcomes of hospital-acquired pressure ulcers: A retrospective review. Critical Care Nurse, 31(4), 30-43. doi:10.4037/ccn2011806 Level of Evidence: 1 – Systematic Reviews, Meta-Analysis, EBP Guidelines Avital, L., Jones, K., Marsden, G., & Stansby, G. (2014). Prevention and management of pressure ulcers in primary and secondary care: summary of NICE guidance. BMJ, 348. doi:10.1136/bmj.g2592 Ayello, E. A. (2012). Predicting pressure ulcer risk. Try This: Best Practices in Nursing Care To Older Adults, 5. Retrieved from http://consultgerirn.org/uploads/File/trythis/try_this_5.pdf Level of Evidence: 4- Cohort Studies or Case Control Studies Curry, M., Hunt, D.R., Kliman, R., Lyder, C.H., Metersky, M., Wang, Y., & Verzier, N.R. (2012). Hospital-acquired pressure ulcers: Results from the national medicare patient safety monitoring system study. Journal of The American Geriatrics Society, 60(9), 1603-1608. doi:10.1111/j.1532-5415.2012.04106.x Level of Evidence: 2 – Randomized Controlled Trial Barrett, R., Bergstrom, N., Horn, S. D., Rapp, M. P., Stern, A., & Watkiss, M. (2013). Turning for ulcer reduction: A multisite randomized clinical trial in nursing homes. Journal Of The American Geriatrics Society, 61(10), 1705-1713. doi:10.1111/jgs.12440 Ishida, I., Kameda, T., Sanada, H., Sato, A., Taguchi, F., Takanao, K.,…Yatabe, S.M. (2013). Mini nutritional assessment as a useful method of predicting the development of pressure ulcers in elderly inpatients. Journal of the American Geriatrics Society, 61(10), 1698-1704. doi:10.1111/jgs.12455 LeMone, P., Lillis, C., Lynne, P., &. Taylor, C.R. (2015). Fundamentals of nursing: The art and science of nursing Care (8th Ed.). Philadelphia: Lippincott.

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