One possible explanation for the findings in this study is that the nutrition subscale of the Braden tool asks the assessing clinician to evaluate the amount of food intake the patient is currently taking in for their usual meals. This assessment is highly subjective and speculative and does not account for recent intake fluctuations or weight loss. By comparison, the VANCS is more comprehensive in its ability to assess nutritional compromise based on multiple factors, such as recent weight loss, laboratory indices, body habitus, dentition, and swallowing ability.20 The National Pressure Ulcer Advisory Panel suggests that following an acute care admission, a patient receive a consult from a dietitian if the health care provider suspects that the patient may be nutritionally compromised.1 The study findings demonstrate the utility of the VANCS as predictive of PrU risk.
Unfortunately, the authors have learned that the VANCS may be phased out soon, and many VA facilities are no longer using it. Findings from this study and other recent scientific literature suggest that all inpatients may benefit from nutritional assessments by dietitians. When performed, dietitian assessments provide the basis for more accurate nursing assessment of nutritional risk and targeted interventions. Nursing professionals should be encouraged to review the dietitian assessment and consultation notes and to incorporate this information into a more comprehensive PrU prevention and treatment plan.
Interestingly, in spite of those assessed to have severe nutritional compromise by dietitian assessment (n = 39), very few of these patients (n = 4) had an ICD-9 diagnosis related to malnutrition (ICD-9 codes, 262, 273.8, 269.9, 263.9) entered in their chart for that hospitalization. This observation suggests that 88% of patients with severe nutritional compromise were not appropriately coded at discharge. Improper coding has implications for researchers using ICD-9 diagnosis codes at discharge for accurate analysis of risk factors as well as for health care providers who may look at coded diagnoses information in the charts when considering comorbid conditions for health management.
This study highlights the importance of nutritional status as a risk factor for PrU development. Reasons suggested for nutritional status seeming to be the most significant correlate to PrUs in the acute care setting include the following: decreased protein alters oncotic pressure, making tissue prone to edema; decreases in subcutaneous fat reduce protection from pressure effects; nutritional compromise alters cellular transport of nutrients and waste and makes tissue cells more vulnerable to deformation and physical stresses; and lactate (a by-product of anaerobic glycolysis) or any other metabolic by-product of malnutrition could cause biochemical stress, and tissue cells can die faster as a result of the increased plasma membrane permeability.7,24-26
Limitations
This study was limited to 1 sample of veterans hospitalized in the 2 acute care facilities of NF/SGVHS and the use of a retrospective chart review. As a result, further research is necessary to establish generalizability to other acute care settings and high-risk populations. In spite of these limitations, this and other studies highlight the need for revision of the Braden scale, specifically the nutritional subscale, to lessen the ambiguity seen between dietitian and nursing assessments while also increasing the accuracy in determining a patient’s nutrition risk of PrU development during hospitalization.
Conclusion
These findings provide evidence that dietitians’ documentation of the VANCS related to nutritional compromise are superior to current nutritional risk assessments using the Braden nutrition subscale in predicting PrU risk.
Acknowledgments
The authors acknowledge that this work was supported by the resources of the North Florida/South Georgia Veterans Health System in Gainesville, Florida, and in part by a Small Project Award from the VA Office of Nursing Services.
