Journal of Practical & Professional Nursing Category: Clinical Type: Research Article
The Effectiveness of a Mobile Nutrition Application to Promote the Nutritional Status and Wound Healing Rate in Patients with Pressure Ulcers Receiving Long-Term Care in Thailand
- Jinpitcha Mamom1*, Prakaipetch Winaiprasert2
- 1 Faculty Of Nursing, Thailand
- 2 Faculty Of Nursing, Thammasat University, Thailand
*Corresponding Author:Jinpitcha Mamom
Faculty Of Nursing, Thailand
Received Date: Mar 05, 2019 Accepted Date: Mar 25, 2019 Published Date: Apr 02, 2019
BACKGROUND AND SIGNIFICANCE
Body proteins are an important component that are used in the repair of many tissues  by facilitating new blood vessel generation (neovascularization), tissue regeneration (fibroblast), collagen fiber synthesis, and immune system function through the cell-mediated response in the phagocytosis process . Under normal conditions, elderly people require 1 gram of proteins/kilogram of body weight but, when they have pressure ulcers, their bodies need more than 2 grams of proteins per kilogram of body weight . Carbohydrates and fats act as protein-sparing agents and help to promote the functions of leukocytes and fibroblasts, making white blood cells work better so that infections are reduced and wound healing is more rapid . Carbohydrates and fats also provide energy to cells and are essential for leukocyte agglutination. If carbohydrates and fats are deficient in number, protein degradation will occur in the supply of energy . When pressure ulcers develop, the body's energy requirements increase to 35 kilocalories/kilogram of body weight . Since the energy that the body uses should be derived from carbohydrates and fats, energy calculation is based on carbohydrates and fats only, excluding the energy from proteins in order to maintain the body weight. Under normal conditions, our body needs 20-25 kilocalories of energy/kilogram of body weight. Essential minerals, including sodium, potassium, chloride, calcium, and phosphorus, are not only important for collagen synthesis and tissue formation but are also used to maintain normal cellular functions and water homeostasis. The balance of salts and water is important in maintaining blood circulation in tissues . Zinc is involved in the RNA replication process, which is important for cell proliferation. Under normal conditions, our body needs 15 milligrams of dietary zinc/day. When ulcers develop, the body's zinc requirements increase to 225 milligrams/day . Zinc deficiency may cause abnormal lymphocyte functions, resulting in increased risks of infection . Vitamin C is essential for collagen bundling and helps with infection prevention, collagen synthesis, new capillary generation, and blood vessel strengthening so that they are not fragile. In addition, it plays an important role in neutrophil functions. Vitamin C deficiency increases the risks and severity of septic wounds . Vitamin A not only promotes collagen synthesis and cell proliferation, but also stimulates macrophage recruitment around the wound and reduces wound infection. Aqueous materials help maintain the blood circulation system and promote skin integrity. Thus, patients should take at least 2,500 milliliters of water/day if there are no other exceptions .
Currently, malnutrition is a problem that has not been systematically tackled, and therefore, promoting the nutritional status of patients with ulcers is very important. Malnutrition causes wounds to heal slowly and they can easily turn into chronic ulcers, thereby affecting the family, society, and the health system. Therefore, the management of various factors that help prevents wounds and enhances their healing, especially nutritional status promotion , is extremely important. A number of studies have confirmed that malnutrition increases the incidence and degree of pressure ulcers by 2.8 times over those with normal nutritional status . In addition, malnutrition also causes regenerated tissues to lack strength and increases infection rates . The principle of nutritional status promotion in patients with pressure ulcers is to provide complete nutrients as required by each patient. However, food preparation procedures are rather complicated, cumbersome, and multi-step, making it difficult for relatives to care for patients so they do not place importance on the preparation of complete and correct raw materials . This could be the reason underlying the increased incidence of pressure ulcers in community patients.
At present, mobile devices are becoming increasingly important due to their advantages of portability, wireless connection, and light weight. For these reasons, mobile devices have become an indispensable part of daily life. In Thailand, there are no mobile applications that calculate individualized daily energy needs and provide information on the specific nutrients required for each individual to promote the nutritional status of patients with pressure ulcers. However, a large number of supportive mobile apps are being developed to help improve quality of life. Hence, mobile devices and their applications are becoming tremendously important, which will also bring about great change in the healthcare management area. Both the iOS and Android platforms were chosen for our development of a mobile nutrition application to help caregivers calculate the daily energy and food intake off patients in order to improve their nutritional status and to increase their wound healing rate. The application was written in the Objective-C programming language with Code as the integrated development environment.
2. To compare the nutritional status before and after using the mobile nutrition application.
3. To compare the wound healing rates between the groups using the mobile nutrition application with the group receiving conventional care.
4. To compare the wound healing rates before and after using the mobile nutrition application.
1) Patients with all degrees of pressure ulcers that were allowed returning to home-based care.
2) Enteral feeding was prescribed by their doctors.
3) Caregivers could use the application and communicate in Thai correctly.
4) They had no mental disorders.
5) They were willing to participate in the research.
Sample Size Calculation
Research Instrument consisted of two parts:
Part 1: The data collection tools were as follows.
1. Wound healing rate was assessed using the Pressure Ulcer Status Tool (PUSH), which assessed the progression of wound healing in order to detect the different wound size, the amount of secretion, and the wound base appearance. According to the PUSH tool criteria, the maximum score of 17 points indicates a bad wound that heals slowly, where as the minimum score of 0 points indicates that the wound has fully recovered. Wound healing rate was documented on the first and 28th days of enrollment (regularly follow-up schedule for this population).
2. Nutritional status assessment was performed through blood albumin level determination according to the standard method  by using 5 milliliters of blood serum. The assessment was carried out by the investigator on the first and 28th days of enrollment.
Part 2: The tools for conductingthe research included the application for calculating the required daily food intake, which is an operating system that could be accessed by the caregivers on their phones to calculate the energy and food required per day. Both the iOS and Android platforms were chosen to develop the mobile nutrition application that helped the caregivers with the calculations of the daily energy and food intake of the patients in order to improve their nutritional status and to increase the wound healing rate. The application was written in Objective-C programming language with X-code as the integrated development environment. The application work procedure consisted of the following steps.
Step 1: Fill in personal information,including name, age, weight, height, stage of pressure ulcers, so that the system cancalculate the output as theenergy required bythe patient per day.
Step 2: The system calculated the nutrient requirements in each of the five food groupsin order for the patients to receive complete nutrientsby using the equation for Total Energy Expenditure (TEE) = BEE x 1.2 x stress factor.
BEE = 66 + (13.7 x weight [kg] + (5 x height [cm]) - (6.8 x age).
BEE = 655 + (9.6 x weight [kg] + (1.7 x height [cm]) - (4.7 x age).
Stress factor in patients with pressure ulcers.
1st and 5th degree of pressure ulcerstress factor = 1.0.
2nd-4th, 6th degree of pressure ulcerstress factor = 1.15.
Step 3: The system displayed the amount of nutrients in each food group as calculated in Step 2.
Step 4: The system displayed the food categories that provide the calculated energy.
Food formula for anyone who needs 1,017 k cal consists of 61 grams, 34 grams, 117 grams and 545 mgs of protein, fat, carbohydrates and cholesterol respectively. After that, the system will display the list of raw materials belonging to each group of energy sources e.g. (1) raw materials for protein: pork, beef, chicken or fish; (2) raw materials for fat: vegetable oil; (3) raw materials for carbohydrates: sugar, cooked rice; (4) raw materials for cholesterol: eggs; (5) other raw materials: green, yellow vegetables such as kale, gourd, cantonese, pumpkin or carrot. Finally, water must be added to get the final volume of 1,000 cc. The calculated amount of each raw material will lead to the desired final energy of 1,017 kcal for one patient per day.
Evaluations of Research Instruments
Determination of tool reliability
Research Data Analysis
2. Comparison of the nutritional status between the group using the mobile nutrition application and the group receiving regular nursing care was based on independent t-test statistics.
3. Comparison of the nutritional status of the experimental group before and after using the mobile nutrition application was based on paired t-test statistics.
4. Comparison of the wound healing rates between the group using the mobile nutrition application and the group receiving regular nursing care was based on independent t-test statistics.
5. Comparison of the wound healing rates of the experimental group before and after using the mobile nutrition application was based on paired t-test statistics.
PROCEDURE OF THE INTERVENTION AND DATA COLLECTION
In intervention groups, the researcher educated them overall about PUs, the method of PUs prevention, nutrition care, and how to calculate energy and food per day according to this application and gave a demonstration and return demonstration until the researcher was certain that the caregivers were able to use and manage the application appropriately. Meanwhile, in the control group, the researcher educated them overall about PUs, the method of PUs prevention, nutrition care, and how to calculate energy and food per day according to the manual from the nutrition department and gave a demonstration and return demonstration until the researcher was certain that the caregivers were able to calculate energy and food appropriately.
Part 2: Comparison of the blood albumin levels between the experimental group using the mobile nutrition application and the control group receiving regular nursing care indicated that the blood albumin levels of the group using the mobile nutrition application were significantly higher than those of the control group receiving regular nursing care at the 0.05 level.
Part 3: Comparison of the blood albumin levels before and after using the mobile nutrition application showed that the blood albumin levels of the experimental group after using the mobile nutrition application were significantly higher than before the mobile nutrition application was used at the 0.05 level.
Part 4: Comparison of the PUSH scores between the experimental group using the mobile nutrition application and the control group receiving regular nursing care demonstrated that the blood albumin levels of the group using the mobile nutrition application were significantly higher than those of the control group receiving regular nursing care at the 0.05 level.
Part 5: Comparison of the wound healing rates before and after using the mobile nutrition application.
Results for Part 5: Comparison of the PUSH scores before and after using the mobile nutrition application showed that, after using the mobile nutrition application, the PUSH scores of the experimental group were significantly higher than before the mobile nutrition application was used at the 0.01 levels.
DISCUSSION OF THE RESULTS
General characteristics of the subjects
Significance of the application for calculating required daily food intake in terms of nutritional status
Significance of the application for calculating the daily energy and food intake in relation to wound healing rate
Features of the application for calculating the required daily food intake that affects nutritional status and wound healing rate
Apart from the direct effectiveness on changes in health factors, the developed application for calculating the required daily food intake is also satisfactory for users. It was found that the caregivers of 36 patients were satisfied with the application for calculating the required daily food intake at the highest level (average 4.51 points). This agrees with the satisfaction theory of Miremberg and colleague, which indicates that satisfaction results from the interaction between users and the service provider that can make users feel positive about the service or innovation that they use, making the users more willing to follow all the steps in the program . As a result, the relatives that used this application prepared correct food so the patients received complete nutrients, thereby having increased album in levels, improved nutritional status, and faster wound healing when compared to the group receiving regular nursing care.
The developed application for calculating required daily food intake is efficient in promoting nutritional status, which consequently makes wound healing faster. This easy-to-use and uncomplicated application was created in conjunction with direct person-to-person education, demonstration, and reverse demonstration in order to ensure that, when returning home, it can be properly implemented by the patient or caregiver, along with symptom follow up at home for continuity of care. This will help patients and relatives/caregivers know, understand, and be able to apply their knowledge to correctly adjust their healthcare behaviors. Thus, the relatives/caregivers will feel that they are a part of the healthcare team, resulting in the desired patient care outcomes. Education along with the creation and application of knowledge in order to lead to innovation is very important at present. If patients and relatives have knowledge and understanding regarding the prevention of pressure ulcers, they can behave correctly. As a result, the occurrence of pressure ulcers in hospitals or when patients are at home will decrease.
- Källman U, Bergstrand S, Ek A C, Engström M, Lindgren M (2016) Nursing staff induced repositionings and immobile patients’ spontaneous movements in nursing care. Int Wound J 13: 1168-1175.
- Auiwattanakul S, Ungpinitpong W, Yutthakasemsunt S, Buranapin S, Chittawatanarat K (2017) Prevalence of Pressure Ulcer and Nutritional Factors Affecting Wound Closure Success in Thailand. Mater Sociomed 29: 196-200.
- Mamom J (2017) The effects of a community-based discharge-planning model for continuing pressure ulcer care on wound healing rates, nutritional status, and infection rates of elderly patients in Thailand. Songklanakarin J Sci Technol 39: 341-346.
- Amir Y, Lohrmann C, Halfens RJ, Schols JM (2017) Pressure ulcers in four Indonesian hospitals: prevalence, patient characteristics, ulcer characteristics, prevention and treatment. Int Wound J 14: 184-193.
- Millar N L, O’Donnell C, McInnes IB, Brint E (2017) Wounds that heal and wounds that don’t - The role of the IL-33/ST2 pathway in tissue repair and tumorigenesis. Semin Cell Dev Biol 61: 41-50.
- Jaffe L, Wu S (2017) The Role of Nutrition in Chronic Wound Care Management. Podiatry management, The Diabatic Food 36: 77-82.
- Yamanaka H, Okada S, Sanada RNH (2017) A multicenter, randomized, controlled study of the use of nutritional supplements containing collagen peptides to facilitate the healing of pressure ulcers. Journal of Nutrition & Intermediary Metabolism 8: 51-59.
- Bishop A, Witts S, Martin T (2018) The role of nutrition in successful wound healing. Journal of Community Nursing 32: 4.
- Cereda E, Klersy C, Andreola M, Pisati R, Schols JM, et al. (2017) Cost-effectiveness of a disease-specific oral nutritional support for pressure ulcer healing. Clin Nutr 36: 246-252.
- Hall JE (2016) Renal Dysfunction, Rather than Nonrenal Vascular Dysfunction, Mediates Salt-Induced Hypertension. Circulation 133: 894-906
- Gammoh N, Rink L (2017) Zinc in infection and inflammation. Nutrients 9: 624.
- Lussi C, Frotzler A, Jenny A, Schaefer DJ, Kressig RW, et al. (2018) Nutritional blood parameters and nutritional risk screening in patients with spinal cord injury and deep pressure ulcer-a retrospective chart analysis. Spinal cord 56: 168-175.
- Boyko TV, Longaker MT, Yang GP (2018) Review of the Current Management of Pressure Ulcers. Adv Wound Care (New Rochelle) 7: 57-67.
- Alhaug J, Gay C L, Henriksen C, Lerdal A (2017) Pressure ulcer is associated with malnutrition as assessed by Nutritional Risk Screening (NRS 2002) in a mixed hospital population. Food Nutr Res 61: 1324230.
- Erdfelder E, Faul F, Buchner A (1996) GPOWER: A general power analysis program. Behavior research methods, instruments, & computers 28: 1-11.
- EPUAP N, NPUAP N (2014) Prevention and treatment of pressure ulcers: quick reference guide. NPUAP/EPUAP/PPPIA, Perth, Australia, Pg no: 1-75.
- Chaboyer W, Bucknall T, Webster J, McInnes E, Gillespie BM, et al. (2016) The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): A cluster randomised trial. Int J Nurs Stud 64: 63-71.
- Zhou Q, Yu T, Liu Y, Shi R, Tian S, et al. (2018) The prevalence and specific characteristics of hospitalised pressure ulcer patients: A multicentre cross?sectional study. J Clin Nurs 27: 694-704.
- Artico M, Dante A, D’angelo D, Lamarca L, Mastroianni C, et al. (2018) Prevalence, incidence and associated factors of pressure ulcers in home palliative care patients: A retrospective chart review. Palliat Med 32: 299-307.
- Barrois B, Colin D, Allaert FA (2018) Prevalence, characteristics and risk factors of pressure ulcers in public and private hospitals care units and nursing homes in France. Hosp Pract 46: 30-36.
- Taylor C (2017) Importance of nutrition in preventing and treating pressure ulcers. Nurs Older People 29: 33-39.
- Cereda E, Schols JM (2018) Nutrition and Pressure Ulcers Science and Practice of Pressure Ulcer Management. Springer Pg no: 41-56
- Patel S, Jacobus-Kantor L, Marshall L, Ritchie C, Kaplinski M, et al. (2013) Mobilizing your medications: an automated medication reminder application for mobile phones and hypertension medication adherence in a high-risk urban population. J Diabetes Sci Technol 7: 630-639.
- Hantsoo L, Criniti S, Khan A, Moseley M, Kincler N, et al. (2018) A Mobile Application for Monitoring and Management of Depressed Mood in a Vulnerable Pregnant Population. Psychiatr Serv 69: 104-107.
- Zhao J, Freeman B, Li M (2016) Can Mobile Phone Apps Influence People’s Health Behavior Change? An Evidence Review. J Med Internet Res 18: 287.
- Miremberg H, Ben-Ari T, Betzer T, Raphaeli H, Gasnier R, et al. (2018) The impact of a daily smartphone-based feedback system among women with gestational diabetes on compliance, glycemic control, satisfaction, and pregnancy outcome: a randomized controlled trial. Am J Obstet Gynecol 218: 451-457.
Citation: Mamom J, Winaiprasert P (2019) The Effectiveness of a Mobile Nutrition Application to Promote the Nutritional Status and Wound Healing Rate in Patients with Pressure Ulcers Receiving Long-Term Care in Thailand. J Pract Prof Nurs: S1002.
Copyright: © 2019 Jinpitcha Mamom, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.